U.S. patent application number 11/811355 was filed with the patent office on 2010-01-28 for uses and compositions for treatment of ankylosing spondylitis.
Invention is credited to Robert L. Wong.
Application Number | 20100021451 11/811355 |
Document ID | / |
Family ID | 41568843 |
Filed Date | 2010-01-28 |
United States Patent
Application |
20100021451 |
Kind Code |
A1 |
Wong; Robert L. |
January 28, 2010 |
Uses and compositions for treatment of ankylosing spondylitis
Abstract
The invention provides methods, uses and compositions for the
treatment of ankylosing spondylitis (AS). The invention describes
methods and uses for treating ankylosing spondylitis, wherein a
TNF.alpha. inhibitor, such as a human TNF.alpha. antibody, or
antigen-binding portion thereof, is used to reduce signs and
symptoms of ankylosing spondylitis in a subject. Also described are
methods for determining the efficacy of a TNF.alpha. inhibitor for
treatment of ankylosing spondylitis in a subject.
Inventors: |
Wong; Robert L.; (Basking
Ridge, NJ) |
Correspondence
Address: |
MCCARTER & ENGLISH, LLP BOSTON
265 Franklin Street
Boston
MA
02110
US
|
Family ID: |
41568843 |
Appl. No.: |
11/811355 |
Filed: |
June 8, 2007 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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60812312 |
Jun 8, 2006 |
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60857352 |
Nov 6, 2006 |
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60858328 |
Nov 10, 2006 |
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Current U.S.
Class: |
424/130.1 |
Current CPC
Class: |
A61P 25/00 20180101;
A61P 29/00 20180101; A61K 2039/505 20130101; C07K 16/241
20130101 |
Class at
Publication: |
424/130.1 |
International
Class: |
A61K 39/395 20060101
A61K039/395; A61P 25/00 20060101 A61P025/00; A61P 29/00 20060101
A61P029/00 |
Claims
1. A method of decreasing pain and fatigue in a subject having AS
comprising administering a human TNF.alpha. antibody, or
antigen-binding portion thereof, to the subject such that pain and
fatigue are decreased.
2. The method of claim 1, wherein the decrease in fatigue in the
subject is determined by a score selected from the group consisting
of FACIT-F, BASDAI, and SF-36.
3. The method of claim 1, wherein the decrease in fatigue is
determined by a decrease of at least about 1.9 in a BASDAI score of
the subject or a decrease of at least about 2.0 in a BASDAI score
of the subject.
4. (canceled)
5. A method of determining the efficacy of a human TNF.alpha.
antibody, or antigen-binding fragment thereof, for treating
ankylosing spondylitis (AS) in a subject comprising determining a
partial remission rate of a patient population having AS and who
was administered the human TNF.alpha. antibody, or antigen-binding
fragment thereof, wherein a partial remission rate of at least
about 20% of the patient population indicates that the human
TNF.alpha. antibody, or antigen-binding fragment thereof, is an
effective human TNF.alpha. antibody, or antigen-binding fragment
thereof, for the treatment of AS.
6. A method of determining the efficacy of a human TNF.alpha.
antibody, or antigen-binding fragment thereof, for treating
ankylosing spondylitis (AS) in a subject comprising determining a
Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
response of a patient population having AS and who was administered
the human TNF.alpha. antibody, or antigen-binding fragment thereof,
wherein the BASDAI response selected from the group comprising a
BASDAI 20 response in at least 60% of the patient population, a
BASDAI 20 response in at least about 70% of the patient population,
a BASDAI 20 response in at least about 80% of the patient
population, a BASDAI 20 response in at least about 85% of the
patient population, a BASDAI 50 response of at least about 23% of
the patient population, a BASDAI 50 response of at least about 30%
of the patient population, a BASDAI 50 response of at least about
40% of the patient population, a BASDAI 50 response of at least
about 50% of the patient population, a BASDAI 50 response of at
least about 60% of the patient population, a BASDAI 70 response in
at least about 10% of the patient population, a BASDAI 70 response
in at least about 20% of the patient population, a BASDAI 70
response in at least about 30% of the patient population, a BASDAI
70 response in at least about 40% of the patient population, and a
BASDAI 70 response in at least about 45% of the patient population,
indicates that the human TNF.alpha. antibody, or antigen-binding
fragment thereof, is an effective human TNF.alpha. antibody, or
antigen-binding fragment thereof, for the treatment of AS.
7-19. (canceled)
20. A method of determining the efficacy of a human TNF.alpha.
antibody, or antigen-binding fragment thereof, for treating
ankylosing spondylitis (AS) in a subject comprising determining a
Assessment in Ankylosing Spondylitis (ASAS) response of a patient
population having AS and who was administered the human TNF.alpha.
antibody, or antigen-binding fragment thereof, wherein the ASAS
response selected from the group consisting of an ASAS20 response
in at least about 27% of the patient population, an ASAS20 response
in at least about 50% of the patient population, an ASAS20 response
in at least about 55% of the patient population, an ASAS20 response
in at least about 70% of the patient population, an ASAS40 response
in at least about 10% of the patient population, an ASAS40 response
in at least about 20% of the patient population, an ASAS40 response
in at least about 30% of the patient population, an ASAS40 response
in at least about 45% of the patient population, an ASAS70 response
in at least about 5% of the patient population, an ASAS70 response
in at least about 20% of the patient population, an ASAS70 response
in at least about 23% of the patient population, an ASAS70 response
in at least about 30% of the patient population, and an ASAS70
response in at least about 40% of the patient population, indicates
that the human TNF.alpha. antibody, or antigen-binding fragment
thereof, is an effective human TNF.alpha. antibody, or
antigen-binding fragment thereof, for the treatment of AS.
21-33. (canceled)
34. The method of claim 6 or 20, further comprising administering
the effective human TNF.alpha. antibody, or antigen-binding
fragment thereof, to a subject for the treatment of AS.
35. A method of treating AS in a subject comprising administering
an effective human TNF.alpha. antibody, or antigen-binding fragment
thereof, to the subject such that AS is treated, wherein the
administration of the effective human TNF.alpha. antibody, or
antigen-binding fragment thereof, was previously identified as
resulting in a response selected from the group consisting of a
BASDAI 20 response in at least about 60% of a patient population
having AS, a BASDAI 50 response in at least about 23% of a patient
population having AS, a BASDAI 70 response in at least about 10% of
a patient population having AS, an ASAS20 response in at least
about 50% of a patient population having AS, an ASAS50 response in
at least about 39% of a patient population having AS, and an ASAS70
response in at least about 5% of a patient population having
AS.
36-41. (canceled)
42. The method of any one of claims 6, 20 or 35, wherein the
TNF.alpha. antibody, or antigen-binding portion thereof, is a
multivalent antibody.
43. The method of any one of claims 6, 20 or 35, wherein the human
TNF.alpha. antibody, or antigen-binding portion thereof, is
golimumab.
44. The method of any one of claims 1, 5, 6, 20, 35 or 42, wherein
the human TNF.alpha. antibody, or antigen-binding portion thereof,
is selected from the group consisting of: i) a human TNF.alpha.
antibody, or antigen-binding portion thereof, that dissociates from
human TNF.alpha. with a K.sub.d of 1.times.10.sup.-8 M or less and
a K.sub.off rate constant of 1.times.10.sup.-3 s.sup.-1 or less,
both determined by surface plasmon resonance, and neutralizes human
TNF.alpha. cytotoxicity in a standard in vitro L929 assay with an
IC.sub.50 of 1.times.10.sup.-7 M or less; ii) a human TNF.alpha.
antibody, or antigen-binding portion thereof, that: a) dissociates
from human TNF.alpha. with a K.sub.off rate constant of
1.times.10.sup.-3 s.sup.-1 or less, as determined by surface
plasmon resonance; b) has a light chain CDR3 domain comprising the
amino acid sequence of SEQ ID NO: 3, or modified from SEQ ID NO: 3
by a single alanine substitution at position 1, 4, 5, 7 or 8 or by
one to five conservative amino acid substitutions at positions 1,
3, 4, 6, 7, 8 and/or 9; c) has a heavy chain CDR3 domain comprising
the amino acid sequence of SEQ ID NO: 4, or modified from SEQ ID
NO: 4 by a single alanine substitution at position 2, 3, 4, 5, 6,
8, 9, 10 or 11 or by one to five conservative amino acid
substitutions at positions 2, 3, 4, 5, 6, 8, 9, 10, 11 and/or 12;
iii) a human TNF.alpha. antibody, or antigen-binding portion
thereof, that comprises a light chain variable region (LCVR) having
a CDR3 domain comprising the amino acid sequence of SEQ ID NO: 3,
or modified from SEQ ID NO: 3 by a single alanine substitution at
position 1, 4, 5, 7 or 8, and comprises a heavy chain variable
region (HCVR) having a CDR3 domain comprising the amino acid
sequence of SEQ ID NO: 4, or modified from SEQ ID NO: 4 by a single
alanine substitution at position 2, 3, 4, 5, 6, 8, 9, 10 or 11; iv)
a human TNF.alpha. antibody, or antigen-binding portion thereof, a
light chain variable region (LCVR) comprising the amino acid
sequence of SEQ ID NO: 1 and a heavy chain variable region (HCVR)
comprising the amino acid sequence of SEQ ID NO: 2; and v)
adalimumab.
45-48. (canceled)
49. The method of any one of claims 1, 5, 6, 20 or 35, wherein the
human TNF.alpha. antibody, or an antigen-binding portion thereof,
is administered to the subject on a biweekly dosing regimen.
50. The method of any one of claims 1, 5, 6, 20 or 35, wherein the
human TNF.alpha. antibody, or an antigen-binding portion thereof,
is administered in a dose of about 40 mg.
51. The method of any one of claims 1, 5, 6, 20 or 35 wherein the
human TNF.alpha. antibody, or an antigen-binding portion thereof,
is administered to the subject subcutaneously.
Description
RELATED APPLICATIONS
[0001] This application claims priority to U.S. Provisional Patent
Application No. 60/812,312, filed on Jun. 8, 2006; U.S. Provisional
Patent Application No. 60/857,352, filed on Nov. 6, 2006; and U.S.
Provisional Patent Application No. 60/858,328, filed on Nov. 10,
2006.
BACKGROUND OF THE INVENTION
[0002] Ankylosing spondylitis (AS) is a chronic, progressive,
inflammatory disease with considerable impact on patient
functioning, well-being, and disability. The prevalence of AS has
traditionally been estimated in the range of 0.1-1.9%, with more
males affected than females (Sieper et al. Ann Rheum Dis 2001;
60:3-18; Silmani & Hochberg Rheum Dis Clin North Am 1996;
22:737-49; Gran & Husby, Semin Arthritis Rheum 1993;
22(5):319-34). Millions of people are affected by ankylosing
spondylitis (AS). As a chronic disease of the axial skeleton and
large peripheral joints, AS causes inflammatory back pain and
stiffness and it is associated with other inflammatory diseases of
the skin, eyes and intestines. AS is difficult to diagnose in its
early stages and is often an overlooked cause of persistent back
pain in young adults. In severe cases, AS may result in complete
spinal fusion, causing extreme physical limitation. Thus, there
remains a need for a safe and effective treatment for AS.
[0003] As the disease progresses, patients with AS experience pain,
joint stiffness, and the eventual loss of spinal mobility. These
clinical symptoms and subsequent disease progression result in
functional limitations and impairment in health-related quality of
life (HRQOL) (Dagfinrud et al. Ann Rheum Dis 2004:63:1605-10;
Bostan et al. Rheumatol Int 2003; 23:121-6; Zink et al., J
Rheumatol 2000; 27:613-22; Ward 1998, Rheum Dis Clin North Am 1998;
24:815-27) and work productivity (Boonen et al. Ann Rheum Dis 2002;
61:429-37; Boonen et al. J Rheumatol 2001; 28:1056-62).
[0004] No cure exists for AS. Generally, treatment includes trying
to relieve pain and stiffness using medications such as
nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and
disease-modifying antirheumatic drugs (DMARDs). In recent years
biologic response modifiers that inhibit TNF activity have become
established therapies for AS.
SUMMARY OF THE INVENTION
[0005] Although TNF.alpha. inhibitors are effective at treating AS,
there remains a need for a more effective treatment option for
subjects suffering from AS, especially in improving the fatigue and
pain associated with the disease and in treating subjects who have
failed more conventional, i.e., DMARD or NSAIDs therapy. Thus,
there also remains a need for improved methods and compositions
that provide a safe and effective treatment of AS using TNF.alpha.
inhibitors.
[0006] The instant invention provides improved methods and
compositions for treating AS. The invention further provides a
means for treating certain subpopulations of patients who have AS.
The invention further provides a means by which the efficacy of a
TNF.alpha. inhibitor for the treatment of AS can be determined.
Each of the examples described herein describes methods and
compositions which can be used to determine whether a TNF.alpha.
inhibitor is effective for treating the given disorder, i.e.
AS.
[0007] The invention provides a method of decreasing pain and
fatigue in a subject having AS comprising administering a human
TNF.alpha. antibody, or antigen-binding portion thereof, to the
subject such that pain and fatigue are decreased. In one
embodiment, the decrease in fatigue in the subject is determined by
a score selected from the group consisting of FACIT-F, BASDAI, and
SF-36. In one embodiment, the decrease in fatigue is determined by
a decrease of at least about 1.9 in a BASDAI score of the subject.
In one embodiment, the decrease in fatigue is determined by a
decrease of at least about 2.0 in a BASDAI score of the
subject.
[0008] The invention also provides a method of inducing partial
remission of AS in a subject comprising administering a human
TNF.alpha. antibody, or antigen-binding portion thereof, to the
subject, such that partial remission of AS is induced.
[0009] The invention further provides a method of treating AS in a
subject who has failed either DMARD therapy or NSAIDs therapy
comprising administering a human TNF.alpha. antibody, or
antigen-binding portion thereof, to the subject, such that AS is
treated.
[0010] The invention includes methods for determining the efficacy
of a TNF.alpha. inhibitor for treating ankylosing spondylitis (AS)
in a subject comprising determining a partial remission rate of a
patient population having AS and who was administered the
TNF.alpha. inhibitor, wherein a partial remission rate of at least
about 20% of the patient population indicates that the TNF.alpha.
inhibitor is an effective TNF.alpha. inhibitor for the treatment of
AS.
[0011] The invention further provides a method of determining the
efficacy of a TNF.alpha. inhibitor for treating ankylosing
spondylitis (AS) in a subject comprising determining a Bath
Ankylosing Spondylitis Disease Activity Index (BASDAI) 20 response
of a patient population having AS and who was administered the
TNF.alpha. inhibitor, wherein a BASDAI 20 response in at least
about 60% of the patient population indicates that the TNF.alpha.
inhibitor is an effective TNF.alpha. inhibitor for the treatment of
AS. In one embodiment, a BASDAI 20 response in at least about 70%
of the patient population indicates that the TNF.alpha. inhibitor
is an effective TNF.alpha. inhibitor for the treatment of AS. In
one embodiment, a BASDAI 20 response in at least about 80% of the
patient population indicates that the TNF.alpha. inhibitor is an
effective TNF.alpha. inhibitor for the treatment of AS. In one
embodiment, a BASDAI 20 response in at least about 85% of the
patient population indicates that the TNF.alpha. inhibitor is an
effective TNF.alpha. inhibitor for the treatment of AS.
[0012] The invention includes a method of determining the efficacy
of a TNF.alpha. inhibitor for treating ankylosing spondylitis (AS)
in a subject comprising determining a Bath Ankylosing Spondylitis
Disease Activity Index (BASDAI) 50 response of a patient population
having AS and who was administered the TNF.alpha. inhibitor,
wherein a BASDAI 50 response in at least about 23% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS. In one embodiment, a
BASDAI 50 response in at least about 30% of the patient population
indicates that the TNF.alpha. inhibitor is an effective TNF.alpha.
inhibitor for the treatment of AS. In one embodiment, a BASDAI 50
response in at least about 40% of the patient population indicates
that the TNF.alpha. inhibitor is an effective TNF.alpha. inhibitor
for the treatment of AS. In one embodiment, a BASDAI 50 response in
at least about 50% of the patient population indicates that the
TNF.alpha. inhibitor is an effective TNF.alpha. inhibitor for the
treatment of AS. In one embodiment, a BASDAI 50 response in at
least about 60% of the patient population indicates that the
TNF.alpha. inhibitor is an effective TNF.alpha. inhibitor for the
treatment of AS.
[0013] The invention further provides a method of determining the
efficacy of a TNF.alpha. inhibitor for treating ankylosing
spondylitis (AS) in a subject comprising determining a Bath
Ankylosing Spondylitis Disease Activity Index (BASDAI) 70 response
of a patient population having AS and who was administered the
TNF.alpha. inhibitor, wherein a BASDAI 70 response in at least
about 10% of the patient population indicates that the TNF.alpha.
inhibitor is an effective TNF.alpha. inhibitor for the treatment of
AS. The invention also includes a BASDAI 70 response in at least
about 20% of the patient population indicates that the TNF.alpha.
inhibitor is an effective TNF.alpha. inhibitor for the treatment of
AS. In one embodiment, a BASDAI 70 response in at least about 30%
of the patient population indicates that the TNF.alpha. inhibitor
is an effective TNF.alpha. inhibitor for the treatment of AS. In
one embodiment, a BASDAI 70 response in at least about 40% of the
patient population indicates that the TNF.alpha. inhibitor is an
effective TNF.alpha. inhibitor for the treatment of AS. In one
embodiment, a BASDAI 70 response in at least about 45% of the
patient population indicates that the TNF.alpha. inhibitor is an
effective TNF.alpha. inhibitor for the treatment of AS.
[0014] The invention describes a method of determining the efficacy
of a TNF.alpha. inhibitor for treating ankylosing spondylitis (AS)
in a subject comprising determining a Assessment in Ankylosing
Spondylitis (ASAS) 20 response of a patient population having AS
and who was administered the TNF.alpha. inhibitor, wherein an
ASAS20 response in at least about 27% of the patient population
indicates that the TNF.alpha. inhibitor is an effective TNF.alpha.
inhibitor for the treatment of AS. In one embodiment, an ASAS20
response in at least about 50% of the patient population indicates
that the TNF.alpha. inhibitor is an effective TNF.alpha. inhibitor
for the treatment of AS. In one embodiment, an ASAS20 response in
at least about 55% of the patient population indicates that the
TNF.alpha. inhibitor is an effective TNF.alpha. inhibitor for the
treatment of AS. In one embodiment, an ASAS20 response in at least
about 70% of the patient population indicates that the TNF.alpha.
inhibitor is an effective TNF.alpha. inhibitor for the treatment of
AS.
[0015] The invention provides a method of determining the efficacy
of a TNF.alpha. inhibitor for treating ankylosing spondylitis (AS)
in a subject comprising determining a Assessment in Ankylosing
Spondylitis (ASAS) 40 response of a patient population having AS
and who was administered the TNF.alpha. inhibitor, wherein an
ASAS40 response in at least about 10% of the patient population
indicates that the TNF.alpha. inhibitor is an effective TNF.alpha.
inhibitor for the treatment of AS. In one embodiment, an ASAS40
response in at least about 20% of the patient population indicates
that the TNF.alpha. inhibitor is an effective TNF.alpha. inhibitor
for the treatment of AS.
In one embodiment, an ASAS40 response in at least about 30% of the
patient population indicates that the TNF.alpha. inhibitor is an
effective TNF.alpha. inhibitor for the treatment of AS. In one
embodiment, an ASAS40 response in at least about 45% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS in the subject.
[0016] The invention includes a method of determining the efficacy
of a TNF.alpha. inhibitor for treating ankylosing spondylitis (AS)
in a subject comprising determining a Assessment in Ankylosing
Spondylitis (ASAS) 70 response of a patient population having AS
and who was administered the TNF.alpha. inhibitor, wherein an
ASAS70 response in at least about 5% of the patient population
indicates that the TNF.alpha. inhibitor is an effective TNF.alpha.
inhibitor for the treatment of AS. In one embodiment, an ASAS70
response in at least about 20% of the patient population indicates
that the TNF.alpha. inhibitor is an effective TNF.alpha. inhibitor
for the treatment of AS in the subject. In one embodiment, an
ASAS70 response in at least about 23% of the patient population
indicates that the TNF.alpha. inhibitor is an effective TNF.alpha.
inhibitor for the treatment of AS in the subject. In one
embodiment, an ASAS70 response in at least about 30% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS in the subject. In one
embodiment, an ASAS70 response in at least about 40% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS in the subject.
[0017] In one embodiment, the invention further comprises
administering the effective TNF.alpha. inhibitor to a subject to
treat AS.
[0018] The invention also includes a method of treating AS in a
subject comprising administering an effective TNF.alpha. inhibitor
to the subject such that AS is treated, wherein the effective
TNF.alpha. inhibitor was previously identified as resulting in a
BASDAI 20 response in at least about 60% of a patient population
having AS and who was administered the TNF.alpha. inhibitor.
[0019] The invention further provides a method of treating AS in a
subject comprising administering an effective TNF.alpha. inhibitor
to the subject such that AS is treated, wherein the effective
TNF.alpha. inhibitor was previously identified as resulting in a
BASDAI 50 response in at least about 23% of a patient population
having AS and who was administered the TNF.alpha. inhibitor.
[0020] The invention provides a method of treating AS in a subject
comprising administering an effective TNF.alpha. inhibitor to the
subject such that AS is treated, wherein the effective TNF.alpha.
inhibitor was previously identified as resulting in a BASDAI 70
response in at least about 10% of a patient population having AS
and who was administered the TNF.alpha. inhibitor.
[0021] The invention also provides a method of treating AS in a
subject comprising administering an effective TNF.alpha. inhibitor
to the subject such that AS is treated, wherein the effective
TNF.alpha. inhibitor was previously identified as resulting in an
ASAS20 response in at least about 50% of a patient population
having AS who was administered the TNF.alpha. inhibitor.
[0022] The invention includes a method of treating AS in a subject
comprising administering an effective human TNF.alpha. antibody, or
antigen-binding portion thereof, to the subject, wherein the
effective human TNF.alpha. antibody, or antigen-binding portion
thereof, was previously identified as achieving an ASAS50 response
in at least about 39% of a patient population having AS who was
administered the human TNF.alpha. antibody, or antigen-binding
portion thereof.
[0023] The invention also includes a method of treating AS in a
subject comprising administering an effective human TNF.alpha.
antibody, or antigen-binding portion thereof, to the subject,
wherein the effective human TNF.alpha. antibody, or antigen-binding
portion thereof, was previously identified as achieving an ASAS70
response in at least about 5% of a patient population having AS who
was administered the human TNF.alpha. antibody, or antigen-binding
portion thereof.
[0024] The invention provides a method for monitoring the
effectiveness of a TNF.alpha. inhibitor for the treatment of
fatigue in a human subject having AS comprising administering the
TNF.alpha. inhibitor to the subject; and determining the
effectiveness of the TNF.alpha. inhibitor using a baseline
FACIT-fatigue score and a FACIT-fatigue score following
administration of the TNF.alpha. inhibitor, wherein either a change
of at least about 7 for the FACIT-fatigue score indicates that the
TNF.alpha. inhibitor is effective at reducing fatigue in a subject
having AS.
[0025] The invention includes a method of testing the effectiveness
of a TNF.alpha. inhibitor for decreasing fatigue in a patient
having AS, comprising comparing a pre-determined FACIT-fatigue
score following treatment of the patient with the TNF.alpha.
inhibitor, with a pre-determined FACIT-fatigue baseline score,
wherein a change of at least about 7 indicates the TNF.alpha.
inhibitor is effective for decreasing fatigue in a patient having
AS.
[0026] The invention includes a method of achieving partial
remission of a patient having AS comprising administering to the
patient a TNF.alpha. inhibitor.
[0027] The invention provides a method for monitoring the
effectiveness of a TNF.alpha. inhibitor for the treatment of
ankylosing spondylitis (AS) in a human subject comprising using a
mean baseline AS Quality of Life Questionnaire (ASQoL) of a patient
population having AS and a mean ASQoL score of the patient
population following administration of the TNF.alpha. inhibitor,
wherein a mean decrease in the ASQoL score of at least about 3
indicates that the TNF.alpha. inhibitor is effective at treating
AS. In one embodiment, the TNF.alpha. inhibitor has already been
administered to the pre-selected patient population.
[0028] The invention also provides a method for monitoring the
effectiveness of a TNF.alpha. inhibitor for the treatment of
ankylosing spondylitis (AS) in a human subject comprising using a
mean baseline Maastricht AS Enthesitis Score (MASES) of a patient
population having AS and a mean MASES score of the patient
population following administration of the TNF.alpha. inhibitor,
wherein a mean decrease in the MASES score of at least about 2
indicates that the TNF.alpha. inhibitor is effective at treating
AS. In one embodiment, the TNF.alpha. inhibitor has already been
administered to the pre-selected patient population.
[0029] The invention also provides a method of testing the
effectiveness of a TNF.alpha. inhibitor for the treatment of
ankylosing spondylitis (AS) comprising using a mean baseline BASDAI
score of a preselected patient population having AS and a mean
BASDAI score of the patient population following administration of
the TNF.alpha. inhibitor, wherein a BASDAI20 response rate in at
least about 70% of the patient population indicates the TNF.alpha.
inhibitor is effective for the treatment of AS.
[0030] The invention further provides a method of testing the
effectiveness of a TNF.alpha. inhibitor for the treatment of
ankylosing spondylitis (AS) comprising using a mean baseline BASDAI
score of a preselected patient population having AS and a mean
BASDAI score of the patient population following administration of
the TNF.alpha. inhibitor, wherein a BASDAI70 response rate in at
least about 25% of the patient population indicates the TNF.alpha.
inhibitor is effective for the treatment of AS.
[0031] In one embodiment, the patient population has a mean BASDAI
of about 6.6.
[0032] In another embodiment, the TNF.alpha. inhibitor is selected
from the group consisting of a TNF.alpha. antibody, or an
antigen-binding portion thereof, a TNF fusion protein, or a
recombinant TNF binding protein.
[0033] In another embodiment, the TNF fusion protein is
etanercept.
[0034] In still another embodiment, the TNF.alpha. antibody, or
antigen-binding portion thereof, is selected from the group
consisting of a chimeric antibody, a humanized antibody, and a
multivalent antibody. In one embodiment, the TNF.alpha. antibody,
or antigen-binding portion thereof, is a human antibody.
[0035] In one embodiment, the TNF.alpha. antibody, or
antigen-binding portion thereof, is an isolated human antibody that
dissociates from human TNF.alpha. with a K.sub.d Of
1.times.10.sup.-8 M or less and a K.sub.off rate constant of
1.times.10.sup.-3 s.sup.-1 or less, both determined by surface
plasmon resonance, and neutralizes human TNF.alpha. cytotoxicity in
a standard in vitro L929 assay with an IC.sub.50 of
1.times.10.sup.-7 M or less.
[0036] In another embodiment, the TNF.alpha. antibody is an
isolated human antibody, or antigen-binding portion thereof, with
the following characteristics:
[0037] a) dissociates from human TNF.alpha. with a K.sub.off rate
constant of 1.times.10.sup.-3 s.sup.-1 or less, as determined by
surface plasmon resonance;
[0038] b) has a light chain CDR3 domain comprising the amino acid
sequence of SEQ ID NO: 3, or modified from SEQ ID NO: 3 by a single
alanine substitution at position 1, 4, 5, 7 or 8 or by one to five
conservative amino acid substitutions at positions 1, 3, 4, 6, 7, 8
and/or 9;
[0039] c) has a heavy chain CDR3 domain comprising the amino acid
sequence of SEQ ID NO: 4, or modified from SEQ ID NO: 4 by a single
alanine substitution at position 2, 3, 4, 5, 6, 8, 9, 10 or 11 or
by one to five conservative amino acid substitutions at positions
2, 3, 4, 5, 6, 8, 9, 10, 11 and/or 12.
[0040] In another embodiment, the TNF.alpha. antibody is an
isolated human antibody, or an antigen binding portion thereof,
with a light chain variable region (LCVR) comprising the amino acid
sequence of SEQ ID NO: 1 and a heavy chain variable region (HCVR)
comprising the amino acid sequence of SEQ ID NO: 2.
[0041] In one embodiment, the human TNF.alpha. antibody, or
antigen-binding portion thereof, is adalimumab.
[0042] In one embodiment, the TNF.alpha. antibody, or
antigen-binding portion thereof, is a 40 mg dose.
[0043] In another embodiment, the TNF.alpha. antibody, or
antigen-binding portion thereof, is administered
subcutaneously.
[0044] In still another embodiment, the TNF.alpha. antibody, or
antigen-binding portion thereof, is infliximab or golimumab.
BRIEF DESCRIPTION OF THE DRAWINGS
[0045] FIG. 1 graphically depicts the improvement of BASDAI20, 50
and 70 after 2, 12 and 52 weeks of treatment with adalimumab.
[0046] FIG. 2 shows the improvement of ASAS20, 40 and 70 criteria
after 2, 12 and 52 weeks of treatment with adalimumab.
[0047] FIG. 3 describes an overview of the Canadian AS study
design. The dashed line indicates the early escape option at Weeks
22, 16, and 20.
[0048] FIG. 4 shows the change in mean FACIT-Fatigue score by
treatment group over time.
[0049] FIG. 5 shows the change in mean BASDAI-fatigue item score by
treatment group over time.
[0050] FIG. 6 shows the mean SF-36 vitality domain score by
treatment group over time.
[0051] FIG. 7 outlines the Study H design. The dashed line
indicates the early escape option at Weeks 22, 16, and 20.
[0052] FIG. 8 graphically depicts the ASA40 response through Week
24. *** Statistically significant at p=0.001 level, wherein the p
value is from Pearson's Chi-square test. ASAS40 values are
imputed.
[0053] FIG. 9 depicts the ASA20 response for those patients who
switched to EET at Week 12 of the Canadian AS study. Data includes
patients who entered early-escape open-label therapy at Week
14.
[0054] FIG. 10 depicts the ASAS20 response time course observed in
patients from the Canadian AS study. Observed analysis excludes
patients with missing data, but includes patients who remained on
randomized study drug or who elected early escape treatment. A
statistically significant difference was present between adalimumab
and placebo treatment groups at the p=0.01 level.
[0055] FIG. 11 graphically depicts the time course of ASAS 20
(Imputed) in patients enrolled in Study H. Patients who received
early escape therapy or discontinued are counted as non-responders
at Weeks 12 and 24. ***Statistically significant at p=0.001
level.
DETAILED DESCRIPTION OF THE INVENTION
I. Definitions
[0056] The term "human TNF.alpha." (abbreviated herein as
hTNF.alpha., or simply hTNF), as used herein, is intended to refer
to a human cytokine that exists as a 17 kD secreted form and a 26
kD membrane associated form, the biologically active form of which
is composed of a trimer of noncovalently bound 17 kD molecules. The
structure of hTNF.alpha. is described further in, for example,
Pennica, D., et al. (1984) Nature 312:724-729; Davis, J. M., et al.
(1987) Biochemistry 26:1322-1326; and Jones, E. Y., et al. (1989)
Nature 338:225-228. The term human TNF.alpha. is intended to
include recombinant human TNF.alpha. (rhTNF.alpha.), which can be
prepared by standard recombinant expression methods or purchased
commercially (R & D Systems, Catalog No. 210-TA, Minneapolis,
Minn.). TNF.alpha. is also referred to as TNF.
[0057] The term "TNF.alpha. inhibitor" includes agents which
interfere with TNF.alpha. activity. The term also includes each of
the anti-TNF.alpha. human antibodies and antibody portions
described herein as well as those described in U.S. Pat. Nos.
6,090,382; 6,258,562; 6,509,015, and in U.S. patent application
Ser. Nos. 09/801,185 and 10/302,356. In one embodiment, the
TNF.alpha. inhibitor used in the invention is an anti-TNF.alpha.
antibody, or a fragment thereof, including infliximab
(Remicade.RTM., Johnson and Johnson; described in U.S. Pat. No.
5,656,272, incorporated by reference herein), CDP571 (a humanized
monoclonal anti-TNF-alpha IgG4 antibody), CDP 870 (a humanized
monoclonal anti-TNF-alpha antibody fragment), an anti-TNF dAb
(Peptech), CNTO 148 (golimumab; Medarex and Centocor, see WO
02/12502), and adalimumab (HUMIRA.RTM. Abbott Laboratories, a human
anti-TNF mAb, described in U.S. Pat. No. 6,090,382 as D2E7).
Additional TNF antibodies which may be used in the invention are
described in U.S. Pat. Nos. 6,593,458; 6,498,237; 6,451,983; and
6,448,380, each of which is incorporated by reference herein. In
another embodiment, the TNF.alpha. inhibitor is a TNF fusion
protein, e.g., etanercept (Enbrel.RTM., Amgen; described in WO
91/03553 and WO 09/406,476, incorporated by reference herein). In
another embodiment, the TNF.alpha. inhibitor is a recombinant TNF
binding protein (r-TBP-I) (Serono).
[0058] The term "antibody", as used herein, is intended to refer to
immunoglobulin molecules comprised of four polypeptide chains, two
heavy (H) chains and two light (L) chains inter-connected by
disulfide bonds. Each heavy chain is comprised of a heavy chain
variable region (abbreviated herein as HCVR or VH) and a heavy
chain constant region. The heavy chain constant region is comprised
of three domains, CH1, CH2 and CH3. Each light chain is comprised
of a light chain variable region (abbreviated herein as LCVR or VL)
and a light chain constant region. The light chain constant region
is comprised of one domain, CL. The VH and VL regions can be
further subdivided into regions of hypervariability, termed
complementarity determining regions (CDR), interspersed with
regions that are more conserved, termed framework regions (FR).
Each VH and VL is composed of three CDRs and four FRs, arranged
from amino-terminus to carboxy-terminus in the following order:
FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. The antibodies of the
invention are described in further detail in U.S. Pat. Nos.
6,090,382; 6,258,562; and 6,509,015, each of which is incorporated
herein by reference in its entirety.
[0059] The term "antigen-binding portion" or "antigen-binding
fragment" of an antibody (or simply "antibody portion"), as used
herein, refers to one or more fragments of an antibody that retain
the ability to specifically bind to an antigen (e.g., hTNF.alpha.).
It has been shown that the antigen-binding function of an antibody
can be performed by fragments of a full-length antibody. Binding
fragments include Fab, Fab', F(ab').sub.2, Fabc, Fv, single chains,
and single-chain antibodies. Examples of binding fragments
encompassed within the term "antigen-binding portion" of an
antibody include (i) a Fab fragment, a monovalent fragment
consisting of the VL, VH, CL and CH1 domains; (ii) a F(ab').sub.2
fragment, a bivalent fragment comprising two Fab fragments linked
by a disulfide bridge at the hinge region; (iii) a Fd fragment
consisting of the VH and CH1 domains; (iv) a Fv fragment consisting
of the VL and VH domains of a single arm of an antibody, (v) a dAb
fragment (Ward et al. (1989) Nature 341:544-546), which consists of
a VH or VL domain; and (vi) an isolated complementarity determining
region (CDR). Furthermore, although the two domains of the Fv
fragment, VL and VH, are coded for by separate genes, they can be
joined, using recombinant methods, by a synthetic linker that
enables them to be made as a single protein chain in which the VL
and VH regions pair to form monovalent molecules (known as single
chain Fv (scFv); see e.g., Bird et al. (1988) Science 242:423-426;
and Huston et al. (1988) Proc. Natl. Acad. Sci. USA 85:5879-5883).
Such single chain antibodies are also intended to be encompassed
within the term "antigen-binding portion" of an antibody. Other
forms of single chain antibodies, such as diabodies are also
encompassed. Diabodies are bivalent, bispecific antibodies in which
VH and VL domains are expressed on a single polypeptide chain, but
using a linker that is too short to allow for pairing between the
two domains on the same chain, thereby forcing the domains to pair
with complementary domains of another chain and creating two
antigen binding sites (see e.g., Holliger et al. (1993) Proc. Natl.
Acad. Sci. USA 90:6444-6448; Poljak et al. (1994) Structure
2:1121-1123). The antibody portions of the invention are described
in further detail in U.S. Pat. Nos. 6,090,382, 6,258,562,
6,509,015, each of which is incorporated herein by reference in its
entirety.
[0060] Still further, an antibody or antigen-binding portion
thereof may be part of a larger immunoadhesion molecules, formed by
covalent or noncovalent association of the antibody or antibody
portion with one or more other proteins or peptides. Examples of
such immunoadhesion molecules include use of the streptavidin core
region to make a tetrameric scFv molecule (Kipriyanov, S. M., et
al. (1995) Human Antibodies and Hybridomas 6:93-101) and use of a
cysteine residue, a marker peptide and a C-terminal polyhistidine
tag to make bivalent and biotinylated scFv molecules (Kipriyanov,
S. M., et al. (1994) Mol. Immunol. 31:1047-1058). Antibody
portions, such as Fab and F(ab').sub.2 fragments, can be prepared
from whole antibodies using conventional techniques, such as papain
or pepsin digestion, respectively, of whole antibodies. Moreover,
antibodies, antibody portions and immunoadhesion molecules can be
obtained using standard recombinant DNA techniques, as described
herein.
[0061] A "conservative amino acid substitution", as used herein, is
one in which one amino acid residue is replaced with another amino
acid residue having a similar side chain. Families of amino acid
residues having similar side chains have been defined in the art,
including basic side chains (e.g., lysine, arginine, histidine),
acidic side chains (e.g., aspartic acid, glutamic acid), uncharged
polar side chains (e.g., glycine, asparagine, glutamine, serine,
threonine, tyrosine, cysteine), nonpolar side chains (e.g.,
alanine, valine, leucine, isoleucine, proline, phenylalanine,
methionine, tryptophan), beta-branched side chains (e.g.,
threonine, valine, isoleucine) and aromatic side chains (e.g.,
tyrosine, phenylalanine, tryptophan, histidine).
[0062] "Chimeric antibodies" refers to antibodies wherein one
portion of each of the amino acid sequences of heavy and light
chains is homologous to corresponding sequences in antibodies
derived from a particular species or belonging to a particular
class, while the remaining segment of the chains is homologous to
corresponding sequences from another species. In one embodiment,
the invention features a chimeric antibody or antigen-binding
fragment, in which the variable regions of both light and heavy
chains mimics the variable regions of antibodies derived from one
species of mammals, while the constant portions are homologous to
the sequences in antibodies derived from another species. In a
preferred embodiment of the invention, chimeric antibodies are made
by grafting CDRs from a mouse antibody onto the framework regions
of a human antibody.
[0063] "Humanized antibodies" refer to antibodies which comprise at
least one chain comprising variable region framework residues
substantially from a human antibody chain (referred to as the
acceptor immunoglobulin or antibody) and at least one
complementarity determining region (CDR) substantially from a
non-human-antibody (e.g., mouse). In addition to the grafting of
the CDRs, humanized antibodies typically undergo further
alterations in order to improve affinity and/or immunogenicity.
[0064] The term "multivalent antibody" refers to an antibody
comprising more than one antigen recognition site. For example, a
"bivalent" antibody has two antigen recognition sites, whereas a
"tetravalent" antibody has four antigen recognition sites. The
terms "monospecific", "bispecific", "trispecific", "tetraspecific",
etc. refer to the number of different antigen recognition site
specificities (as opposed to the number of antigen recognition
sites) present in a multivalent antibody. For example, a
"monospecific" antibody's antigen recognition sites all bind the
same epitope. A "bispecific" or "dual specific" antibody has at
least one antigen recognition site that binds a first epitope and
at least one antigen recognition site that binds a second epitope
that is different from the first epitope. A "multivalent
monospecific" antibody has multiple antigen recognition sites that
all bind the same epitope. A "multivalent bispecific" antibody has
multiple antigen recognition sites, some number of which bind a
first epitope and some number of which bind a second epitope that
is different from the first epitope
[0065] The term "human antibody", as used herein, is intended to
include antibodies having variable and constant regions derived
from human germline immunoglobulin sequences. The human antibodies
of the invention may include amino acid residues not encoded by
human germline immunoglobulin sequences (e.g., mutations introduced
by random or site-specific mutagenesis in vitro or by somatic
mutation in vivo), for example in the CDRs and in particular CDR3.
However, the term "human antibody", as used herein, is not intended
to include antibodies in which CDR sequences derived from the
germline of another mammalian species, such as a mouse, have been
grafted onto human framework sequences.
[0066] The term "recombinant human antibody", as used herein, is
intended to include all human antibodies that are prepared,
expressed, created or isolated by recombinant means, such as
antibodies expressed using a recombinant expression vector
transfected into a host cell (described further below), antibodies
isolated from a recombinant, combinatorial human antibody library
(described further below), antibodies isolated from an animal
(e.g., a mouse) that is transgenic for human immunoglobulin genes
(see e.g., Taylor et al. (1992) Nucl. Acids Res. 20:6287) or
antibodies prepared, expressed, created or isolated by any other
means that involves splicing of human immunoglobulin gene sequences
to other DNA sequences. Such recombinant human antibodies have
variable and constant regions derived from human germline
immunoglobulin sequences. In certain embodiments, however, such
recombinant human antibodies are subjected to in vitro mutagenesis
(or, when an animal transgenic for human Ig sequences is used, in
vivo somatic mutagenesis) and thus the amino acid sequences of the
VH and VL regions of the recombinant antibodies are sequences that,
while derived from and related to human germline VH and VL
sequences, may not naturally exist within the human antibody
germline repertoire in vivo.
[0067] Such chimeric, humanized, human, and dual specific
antibodies can be produced by recombinant DNA techniques known in
the art, for example using methods described in PCT International
Application No. PCT/US86/02269; European Patent Application No.
184,187; European Patent Application No. 171,496; European Patent
Application No. 173,494; PCT International Publication No. WO
86/01533; U.S. Pat. No. 4,816,567; European Patent Application No.
125,023; Better et al. (1988) Science 240:1041-1043; Liu et al.
(1987) Proc. Natl. Acad. Sci. USA 84:3439-3443; Liu et al. (1987)
J. Immunol. 139:3521-3526; Sun et al. (1987) Proc. Natl. Acad. Sci.
USA 84:214-218; Nishimura et al. (1987) Cancer Res. 47:999-1005;
Wood et al. (1985) Nature 314:446-449; Shaw et al. (1988) J. Natl.
Cancer Inst. 80:1553-1559); Morrison (1985) Science 229:1202-1207;
Oi et al. (1986) BioTechniques 4:214; U.S. Pat. No. 5,225,539;
Jones et al. (1986) Nature 321:552-525; Verhoeyan et al. (1988)
Science 239:1534; and Beidler et al. (1988) J. Immunol.
141:4053-4060, Queen et al., Proc. Natl. Acad. Sci. USA
86:10029-10033 (1989), U.S. Pat. No. 5,530,101, U.S. Pat. No.
5,585,089, U.S. Pat. No. 5,693,761, U.S. Pat. No. 5,693,762, Selick
et al., WO 90/07861, and Winter, U.S. Pat. No. 5,225,539.
[0068] An "isolated antibody", as used herein, is intended to refer
to an antibody that is substantially free of other antibodies
having different antigenic specificities (e.g., an isolated
antibody that specifically binds hTNF.alpha. is substantially free
of antibodies that specifically bind antigens other than
hTNF.alpha.). An isolated antibody that specifically binds
hTNF.alpha. may, however, have cross-reactivity to other antigens,
such as TNF.alpha. molecules from other species. Moreover, an
isolated antibody may be substantially free of other cellular
material and/or chemicals.
[0069] A "neutralizing antibody", as used herein (or an "antibody
that neutralized hTNF.alpha. activity"), is intended to refer to an
antibody whose binding to hTNF.alpha. results in inhibition of the
biological activity of hTNF.alpha.. This inhibition of the
biological activity of hTNF.alpha. can be assessed by measuring one
or more indicators of hTNF.alpha. biological activity, such as
hTNF.alpha.-induced cytotoxicity (either in vitro or in vivo),
hTNF.alpha..alpha.-induced cellular activation and hTNF.alpha.
binding to hTNF.alpha. receptors. These indicators of hTNF.alpha.
biological activity can be assessed by one or more of several
standard in vitro or in vivo assays known in the art (see U.S. Pat.
No. 6,090,382). Preferably, the ability of an antibody to
neutralize hTNF.alpha. activity is assessed by inhibition of
hTNF.alpha.-induced cytotoxicity of L929 cells. As an additional or
alternative parameter of hTNF.alpha. activity, the ability of an
antibody to inhibit hTNF.alpha.-induced expression of ELAM-1 on
HUVEC, as a measure of hTNF.alpha.-induced cellular activation, can
be assessed.
[0070] The term "surface plasmon resonance", as used herein, refers
to an optical phenomenon that allows for the analysis of real-time
biospecific interactions by detection of alterations in protein
concentrations within a biosensor matrix, for example using the
BIAcore system (Pharmacia Biosensor AB, Uppsala, Sweden and
Piscataway, N.J.). For further descriptions, see Example 1 of U.S.
Pat. No. 6,258,562 and Jonsson et al. (1993) Ann. Biol. Clin.
51:19; Jonsson et al. (1991) Biotechniques 11:620-627; Johnsson et
al. (1995) J. Mol. Recognit. 8:125; and Johnnson et al. (1991)
Anal. Biochem. 198:268.
[0071] The term "K.sub.off", as used herein, is intended to refer
to the off rate constant for dissociation of an antibody from the
antibody/antigen complex.
[0072] The term "K.sub.d", as used herein, is intended to refer to
the dissociation constant of a particular antibody-antigen
interaction.
[0073] The term "IC.sub.50" as used herein, is intended to refer to
the concentration of the inhibitor required to inhibit the
biological endpoint of interest, e.g., neutralize cytotoxicity
activity.
[0074] The term "dose," as used herein, refers to an amount of
TNF.alpha. inhibitor which is administered to a subject.
[0075] The term "dosing", as used herein, refers to the
administration of a substance (e.g., an anti-TNF.alpha. antibody)
to achieve a therapeutic objective (e.g., treatment of ankylosing
spondylitis (AS)).
[0076] A "dosing regimen" describes a treatment schedule for a
TNF.alpha. inhibitor, e.g., a treatment schedule over a prolonged
period of time and/or throughout the course of treatment, e.g.
administering a first dose of a TNF.alpha. inhibitor at week 0
followed by a second dose of a TNF.alpha. inhibitor on a biweekly
dosing regimen.
[0077] The terms "biweekly dosing regimen", "biweekly dosing", and
"biweekly administration", as used herein, refer to the time course
of administering a substance (e.g., an anti-TNF.alpha. antibody) to
a subject to achieve a therapeutic objective, e.g, throughout the
course of treatment. The biweekly dosing regimen is not intended to
include a weekly dosing regimen. Preferably, the substance is
administered every 9-19 days, more preferably, every 11-17 days,
even more preferably, every 13-15 days, and most preferably, every
14 days. In one embodiment, the biweekly dosing regimen is
initiated in a subject at week 0 of treatment. In one embodiment,
biweekly dosing includes a dosing regimen wherein doses of a
TNF.alpha. inhibitor are administered to a subject every other week
beginning at week 0. In one embodiment, biweekly dosing includes a
dosing regimen where doses of a TNF.alpha. inhibitor are
administered to a subject every other week consecutively for a
given time period, e.g., 4 weeks, 8 weeks, 16, weeks, 24 weeks,
etc. Biweekly dosing methods are also described in US 20030235585,
incorporated by reference herein.
[0078] The term "combination" as in the phrase "a first agent in
combination with a second agent" includes co-administration of a
first agent and a second agent, which for example may be dissolved
or intermixed in the same pharmaceutically acceptable carrier, or
administration of a first agent, followed by the second agent, or
administration of the second agent, followed by the first agent.
The present invention, therefore, includes methods of combination
therapeutic treatment and combination pharmaceutical compositions.
In one embodiment, a TNF.alpha. antibody is administered in
combination with methotrexate for the treatment of ankylosing
spondylitis.
[0079] The term "concomitant" as in the phrase "concomitant
therapeutic treatment" includes administering an agent in the
presence of a second agent. A concomitant therapeutic treatment
method includes methods in which the first, second, third, or
additional agents are co-administered. A concomitant therapeutic
treatment method also includes methods in which the first or
additional agents are administered in the presence of a second or
additional agents, wherein the second or additional agents, for
example, may have been previously administered. A concomitant
therapeutic treatment method may be executed step-wise by different
actors. For example, one actor may administer to a subject a first
agent and a second actor may to administer to the subject a second
agent, and the administering steps may be executed at the same
time, or nearly the same time, or at distant times, so long as the
first agent (and additional agents) are after administration in the
presence of the second agent (and additional agents). The actor and
the subject may be the same entity (e.g., human).
[0080] The term "combination therapy", as used herein, refers to
the administration of two or more therapeutic substances, e.g., an
anti-TNF.alpha. antibody and another drug. The other drug(s) may be
administered concomitant with, prior to, or following the
administration of an anti-TNF.alpha. antibody.
[0081] The term "treatment," as used within the context of the
present invention, is meant to include therapeutic treatment, as
well as prophylactic or suppressive measures, for the treatment of
ankylosing spondylitis. For example, the term treatment may include
administration of a TNF.alpha. inhibitor prior to or following the
onset of ankylosing spondylitis thereby preventing or removing
signs of the disease or disorder. As another example,
administration of a TNF.alpha. inhibitor after clinical
manifestation of ankylosing spondylitis to combat the symptoms
and/or complications and disorders associated with ankylosing
spondylitis comprises "treatment" of the disease. Further,
administration of the agent after onset and after clinical symptoms
and/or complications have developed where administration affects
clinical parameters of the disease or disorder and perhaps
amelioration of the disease, comprises "treatment" of the
ankylosing spondylitis.
[0082] Those "in need of treatment" include mammals, such as
humans, already having AS, including those in which the disease or
disorder is to be prevented.
[0083] The invention provides improved uses and compositions for
treating ankylosing spondylitis with a TNF.alpha. inhibitor, e.g.,
a human TNF.alpha. antibody, or an antigen-binding portion thereof.
Compositions and articles of manufacture, including kits, relating
to the methods and uses for treating ankylosing spondylitis are
also contemplated as part of the invention. Various aspects of the
invention are described in further detail herein.
II. TNF Inhibitors
[0084] A TNF.alpha. inhibitor which is used in the methods and
compositions of the invention includes any agent which interferes
with TNF.alpha. activity. In a preferred embodiment, the TNF.alpha.
inhibitor can neutralize TNF.alpha. activity, particularly
detrimental TNF.alpha. activity which is associated with ankylosing
spondylitis, and related complications and symptoms.
[0085] In one embodiment, the TNF.alpha. inhibitor used in the
invention is an TNF.alpha. antibody (also referred to herein as a
TNF.alpha. antibody), or an antigen-binding fragment thereof,
including chimeric, humanized, and human antibodies. Examples of
TNF.alpha. antibodies which may be used in the invention include,
but not limited to, infliximab (Remicade.RTM., Johnson and Johnson;
described in U.S. Pat. No. 5,656,272, incorporated by reference
herein), CDP571 (a humanized monoclonal anti-TNF-alpha IgG4
antibody), CDP 870 (a humanized monoclonal anti-TNF-alpha antibody
fragment), an anti-TNF dAb (Peptech), CNTO 148 (golimumab; Medarex
and Centocor, see WO 02/12502), and adalimumab (HUMIRA.RTM. Abbott
Laboratories, a human anti-TNF mAb, described in U.S. Pat. No.
6,090,382 as D2E7). Additional TNF antibodies which may be used in
the invention are described in U.S. Pat. Nos. 6,593,458; 6,498,237;
6,451,983; and 6,448,380, each of which is incorporated by
reference herein.
[0086] Other examples of TNF.alpha. inhibitors which may be used in
the methods and compositions of the invention include etanercept
(Enbrel, described in WO 91/03553 and WO 09/406476), soluble TNF
receptor Type I, a pegylated soluble TNF receptor Type I (PEGs
TNF-R1), p55TNFR1gG (Lenercept), and recombinant TNF binding
protein (r-TBP-I) (Serono).
[0087] In one embodiment, the term "TNF.alpha. inhibitor" excludes
infliximab. In one embodiment, the term "TNF.alpha. inhibitor"
excludes adalimumab. In another embodiment, the term "TNF.alpha.
inhibitor" excludes adalimumab and infliximab.
[0088] In one embodiment, the term "TNF.alpha. inhibitor" excludes
etanercept, and, optionally, adalimumab, infliximab, or adalimumab
and infliximab.
[0089] In one embodiment, the term "TNF.alpha. antibody" excludes
infliximab. In one embodiment, the term "TNF.alpha. antibody"
excludes adalimumab. In another embodiment, the term "TNF.alpha.
antibody" excludes adalimumab and infliximab.
[0090] In one embodiment, the invention features uses and
composition for treating or determining the efficacy of a
TNF.alpha. inhibitor for the treatment of ankylosing spondylitis,
wherein the TNF.alpha. antibody is an isolated human antibody, or
antigen-binding portion thereof, that binds to human TNF.alpha.
with high affinity and a low off rate, and also has a high
neutralizing capacity. Preferably, the human antibodies used in the
invention are recombinant, neutralizing human anti-hTNF.alpha.
antibodies. The most preferred recombinant, neutralizing antibody
of the invention is referred to herein as D2E7, also referred to as
HUMIRA.RTM. or adalimumab (the amino acid sequence of the D2E7 VL
region is shown in SEQ ID NO: 1; the amino acid sequence of the
D2E7 VH region is shown in SEQ ID NO: 2). The properties of D2E7
(adalimumab/HUMIRA.RTM.) have been described in Salfeld et al.,
U.S. Pat. Nos. 6,090,382, 6,258,562, and 6,509,015, which are each
incorporated by reference herein. The methods of the invention may
also be performed using chimeric and humanized murine
anti-hTNF.alpha. antibodies which have undergone clinical testing
for treatment of rheumatoid arthritis (see e.g., Elliott, M. J., et
al. (1994) Lancet 344:1125-1127; Elliot, M. J., et al. (1994)
Lancet 344:1105-1110; Rankin, E. C., et al. (1995) Br. J.
Rheumatol. 34:334-342).
[0091] In one embodiment, the method of the invention includes
determining the efficacy of a TNF.alpha. inhibitor, including human
antibodies and antibody portions with equivalent properties to
D2E7, such as high affinity binding to hTNF.alpha. with low
dissociation kinetics and high neutralizing capacity, for the
treatment of ankylosing spondylitis. In one embodiment, the
invention provides treatment with an isolated human antibody, or an
antigen-binding portion thereof, that dissociates from human
TNF.alpha. with a K.sub.d of 1.times.10.sup.-8 M or less and a
K.sub.off rate constant of 1.times.10.sup.-3 s.sup.-1 or less, both
determined by surface plasmon resonance, and neutralizes human
TNF.alpha. cytotoxicity in a standard in vitro L929 assay with an
IC.sub.50 Of 1.times.10.sup.-7 M or less. More preferably, the
isolated human antibody, or antigen-binding portion thereof,
dissociates from human TNF.alpha. with a K.sub.off of
5.times.10.sup.-4 s.sup.-1 or less, or even more preferably, with a
K.sub.off of 1.times.10.sup.-4 s.sup.-1 or less. More preferably,
the isolated human antibody, or antigen-binding portion thereof,
neutralizes human TNF.alpha. cytotoxicity in a standard in vitro
L929 assay with an IC.sub.50 of 1.times.10.sup.-8 M or less, even
more preferably with an IC.sub.50 of 1.times.10.sup.-9 M or less
and still more preferably with an IC.sub.50 of 1.times.10.sup.-10 M
or less. In a preferred embodiment, the antibody is an isolated
human recombinant antibody, or an antigen-binding portion
thereof.
[0092] It is well known in the art that antibody heavy and light
chain CDR3 domains play an important role in the binding
specificity/affinity of an antibody for an antigen. Accordingly, in
another aspect, the invention pertains to treating AS by
administering human antibodies that have slow dissociation kinetics
for association with hTNF.alpha. and that have light and heavy
chain CDR3 domains that structurally are identical to or related to
those of D2E7. Position 9 of the D2E7 VL CDR3 can be occupied by
Ala or Thr without substantially affecting the K.sub.off.
Accordingly, a consensus motif for the D2E7 VL CDR3 comprises the
amino acid sequence: Q-R-Y-N-R-A-P-Y-(T/A) (SEQ ID NO: 3).
Additionally, position 12 of the D2E7 VH CDR3 can be occupied by
Tyr or Asn, without substantially affecting the K.sub.off.
Accordingly, a consensus motif for the D2E7 VH CDR3 comprises the
amino acid sequence: V-S-Y-L-S-T-A-S-S-L-D-(Y/N) (SEQ ID NO: 4).
Moreover, as demonstrated in Example 2 of U.S. Pat. No. 6,090,382,
the CDR3 domain of the D2E7 heavy and light chains is amenable to
substitution with a single alanine residue (at position 1, 4, 5, 7
or 8 within the VL CDR3 or at position 2, 3, 4, 5, 6, 8, 9, 10 or
11 within the VH CDR3) without substantially affecting the
K.sub.off. Still further, the skilled artisan will appreciate that,
given the amenability of the D2E7 VL and VH CDR3 domains to
substitutions by alanine, substitution of other amino acids within
the CDR3 domains may be possible while still retaining the low off
rate constant of the antibody, in particular substitutions with
conservative amino acids. Preferably, no more than one to five
conservative amino acid substitutions are made within the D2E7 VL
and/or VH CDR3 domains. More preferably, no more than one to three
conservative amino acid substitutions are made within the D2E7 VL
and/or VH CDR3 domains. Additionally, conservative amino acid
substitutions should not be made at amino acid positions critical
for binding to hTNF.alpha.. Positions 2 and 5 of the D2E7 VL CDR3
and positions 1 and 7 of the D2E7 VH CDR3 appear to be critical for
interaction with hTNF.alpha. and thus, conservative amino acid
substitutions preferably are not made at these positions (although
an alanine substitution at position 5 of the D2E7 VL CDR3 is
acceptable, as described above) (see U.S. Pat. No. 6,090,382).
[0093] Accordingly, in another embodiment, the antibody or
antigen-binding portion thereof preferably contains the following
characteristics:
[0094] a) dissociates from human TNF.alpha. with a K.sub.off rate
constant of 1.times.10.sup.-3 s.sup.-1 or less, as determined by
surface plasmon resonance;
[0095] b) has a light chain CDR3 domain comprising the amino acid
sequence of SEQ ID NO: 3, or modified from SEQ ID NO: 3 by a single
alanine substitution at position 1, 4, 5, 7 or 8 or by one to five
conservative amino acid substitutions at positions 1, 3, 4, 6, 7, 8
and/or 9;
[0096] c) has a heavy chain CDR3 domain comprising the amino acid
sequence of SEQ ID NO: 4, or modified from SEQ ID NO: 4 by a single
alanine substitution at position 2, 3, 4, 5, 6, 8, 9, 10 or 11 or
by one to five conservative amino acid substitutions at positions
2, 3, 4, 5, 6, 8, 9, 10, 11 and/or 12.
[0097] More preferably, the antibody, or antigen-binding portion
thereof, dissociates from human TNF.alpha. with a K.sub.off of
5.times.10.sup.-4 s.sup.-1 or less. Even more preferably, the
antibody, or antigen-binding portion thereof, dissociates from
human TNF.alpha. with a K.sub.off of 1.times.10.sup.-4 s.sup.-1 or
less.
[0098] In yet another embodiment, the antibody or antigen-binding
portion thereof preferably contains a light chain variable region
(LCVR) having a CDR3 domain comprising the amino acid sequence of
SEQ ID NO: 3, or modified from SEQ ID NO: 3 by a single alanine
substitution at position 1, 4, 5, 7 or 8, and with a heavy chain
variable region (HCVR) having a CDR3 domain comprising the amino
acid sequence of SEQ ID NO: 4, or modified from SEQ ID NO: 4 by a
single alanine substitution at position 2, 3, 4, 5, 6, 8, 9, 10 or
11. Preferably, the LCVR further has a CDR2 domain comprising the
amino acid sequence of SEQ ID NO: 5 (i.e., the D2E7 VL CDR2) and
the HCVR further has a CDR2 domain comprising the amino acid
sequence of SEQ ID NO: 6 (i.e., the D2E7 VH CDR2). Even more
preferably, the LCVR further has CDR1 domain comprising the amino
acid sequence of SEQ ID NO: 7 (i.e., the D2E7 VL CDR1) and the HCVR
has a CDR1 domain comprising the amino acid sequence of SEQ ID NO:
8 (i.e., the D2E7 VH CDR1). The framework regions for VL preferably
are from the V.sub..kappa.I human germline family, more preferably
from the A20 human germline Vk gene and most preferably from the
D2E7 VL framework sequences shown in FIGS. 1A and 1B of U.S. Pat.
No. 6,090,382. The framework regions for VH preferably are from the
V.sub.H3 human germline family, more preferably from the DP-31
human germline VH gene and most preferably from the D2E7 VH
framework sequences shown in FIGS. 2A and 2B of U.S. Pat. No.
6,090,382.
[0099] Accordingly, in another embodiment, the antibody or
antigen-binding portion thereof preferably contains a light chain
variable region (LCVR) comprising the amino acid sequence of SEQ ID
NO: 1 (i.e., the D2E7 VL) and a heavy chain variable region (HCVR)
comprising the amino acid sequence of SEQ ID NO: 2 (i.e., the D2E7
VH). In certain embodiments, the antibody comprises a heavy chain
constant region, such as an IgG1, IgG2, IgG3, IgG4, IgA, IgE, IgM
or IgD constant region. Preferably, the heavy chain constant region
is an IgG1 heavy chain constant region or an IgG4 heavy chain
constant region. Furthermore, the antibody can comprise a light
chain constant region, either a kappa light chain constant region
or a lambda light chain constant region. Preferably, the antibody
comprises a kappa light chain constant region. Alternatively, the
antibody portion can be, for example, a Fab fragment or a single
chain Fv fragment.
[0100] In still other embodiments, the invention includes uses of
an isolated human antibody, or an antigen-binding portions thereof,
containing D2E7-related VL and VH CDR3 domains. For example,
antibodies, or antigen-binding portions thereof, with a light chain
variable region (LCVR) having a CDR3 domain comprising an amino
acid sequence selected from the group consisting of SEQ ID NO: 3,
SEQ ID NO: 11, SEQ ID NO: 12, SEQ ID NO: 13, SEQ ID NO: 14, SEQ ID
NO: 15, SEQ ID NO: 16, SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19,
SEQ ID NO: 20, SEQ ID NO: 21, SEQ ID NO: 22, SEQ ID NO: 23, SEQ ID
NO: 24, SEQ ID NO: 25 and SEQ ID NO: 26 or with a heavy chain
variable region (HCVR) having a CDR3 domain comprising an amino
acid sequence selected from the group consisting of SEQ ID NO: 4,
SEQ ID NO: 27, SEQ ID NO: 28, SEQ ID NO: 29, SEQ ID NO: 30, SEQ ID
NO: 31, SEQ ID NO: 32, SEQ ID NO: 33, SEQ ID NO: 34 and SEQ ID NO:
35.
[0101] The TNF.alpha. antibody used in the methods and compositions
of the invention may be modified for improved treatment of
ankylosing spondylitis. In some embodiments, the TNF.alpha.
antibody or antigen binding fragments thereof, is chemically
modified to provide a desired effect. For example, pegylation of
antibodies and antibody fragments of the invention may be carried
out by any of the pegylation reactions known in the art, as
described, for example, in the following references: Focus on
Growth Factors 3:4-10 (1992); EP 0 154 316; and EP 0 401 384 (each
of which is incorporated by reference herein in its entirety).
Preferably, the pegylation is carried out via an acylation reaction
or an alkylation reaction with a reactive polyethylene glycol
molecule (or an analogous reactive water-soluble polymer). A
preferred water-soluble polymer for pegylation of the antibodies
and antibody fragments of the invention is polyethylene glycol
(PEG). As used herein, "polyethylene glycol" is meant to encompass
any of the forms of PEG that have been used to derivatize other
proteins, such as mono (Cl-ClO) alkoxy- or aryloxy-polyethylene
glycol.
[0102] Methods for preparing pegylated antibodies and antibody
fragments of the invention will generally comprise the steps of (a)
reacting the antibody or antibody fragment with polyethylene
glycol, such as a reactive ester or aldehyde derivative of PEG,
under conditions whereby the antibody or antibody fragment becomes
attached to one or more PEG groups, and (b) obtaining the reaction
products. It will be apparent to one of ordinary skill in the art
to select the optimal reaction conditions or the acylation
reactions based on known parameters and the desired result.
[0103] Pegylated antibodies and antibody fragments may generally be
used to treat ankylosing spondylitis by administration of the
TNF.alpha. antibodies and antibody fragments described herein.
Generally the pegylated antibodies and antibody fragments have
increased half-life, as compared to the nonpegylated antibodies and
antibody fragments. The pegylated antibodies and antibody fragments
may be employed alone, together, or in combination with other
pharmaceutical compositions.
[0104] In yet another embodiment of the invention, TNF.alpha.
antibodies or fragments thereof can be altered wherein the constant
region of the antibody is modified to reduce at least one constant
region-mediated biological effector function relative to an
unmodified antibody. To modify an antibody of the invention such
that it exhibits reduced binding to the Fc receptor, the
immunoglobulin constant region segment of the antibody can be
mutated at particular regions necessary for Fc receptor (FcR)
interactions (see e.g., Canfield, S. M. and S. L. Morrison (1991)
J. Exp. Med. 173:1483-1491; and Lund, J. et al. (1991) J. of
Immunol. 147:2657-2662). Reduction in FcR binding ability of the
antibody may also reduce other effector functions which rely on FcR
interactions, such as opsonization and phagocytosis and
antigen-dependent cellular cytotoxicity.
[0105] An antibody or antibody portion used in the methods of the
invention can be derivatized or linked to another functional
molecule (e.g., another peptide or protein). Accordingly, the
antibodies and antibody portions of the invention are intended to
include derivatized and otherwise modified forms of the human
anti-hTNF.alpha. antibodies described herein, including
immunoadhesion molecules. For example, an antibody or antibody
portion of the invention can be functionally linked (by chemical
coupling, genetic fusion, noncovalent association or otherwise) to
one or more other molecular entities, such as another antibody
(e.g., a bispecific antibody or a diabody), a detectable agent, a
cytotoxic agent, a pharmaceutical agent, and/or a protein or
peptide that can mediate associate of the antibody or antibody
portion with another molecule (such as a streptavidin core region
or a polyhistidine tag).
[0106] One type of derivatized antibody is produced by crosslinking
two or more antibodies (of the same type or of different types,
e.g., to create bispecific antibodies). Suitable crosslinkers
include those that are heterobifunctional, having two distinctly
reactive groups separated by an appropriate spacer (e.g.,
m-maleimidobenzoyl-N-hydroxysuccinimide ester) or homobifunctional
(e.g., disuccinimidyl suberate). Such linkers are available from
Pierce Chemical Company, Rockford, Ill.
[0107] Useful detectable agents with which an antibody or antibody
portion of the invention may be derivatized include fluorescent
compounds. Exemplary fluorescent detectable agents include
fluorescein, fluorescein isothiocyanate, rhodamine,
5-dimethylamine-1-napthalenesulfonyl chloride, phycoerythrin and
the like. An antibody may also be derivatized with detectable
enzymes, such as alkaline phosphatase, horseradish peroxidase,
glucose oxidase and the like. When an antibody is derivatized with
a detectable enzyme, it is detected by adding additional reagents
that the enzyme uses to produce a detectable reaction product. For
example, when the detectable agent horseradish peroxidase is
present, the addition of hydrogen peroxide and diaminobenzidine
leads to a colored reaction product, which is detectable. An
antibody may also be derivatized with biotin, and detected through
indirect measurement of avidin or streptavidin binding.
[0108] An antibody, or antibody portion, used in the methods and
compositions of the invention, can be prepared by recombinant
expression of immunoglobulin light and heavy chain genes in a host
cell. To express an antibody recombinantly, a host cell is
transfected with one or more recombinant expression vectors
carrying DNA fragments encoding the immunoglobulin light and heavy
chains of the antibody such that the light and heavy chains are
expressed in the host cell and, preferably, secreted into the
medium in which the host cells are cultured, from which medium the
antibodies can be recovered. Standard recombinant DNA methodologies
are used to obtain antibody heavy and light chain genes,
incorporate these genes into recombinant expression vectors and
introduce the vectors into host cells, such as those described in
Sambrook, Fritsch and Maniatis (eds), Molecular Cloning; A
Laboratory Manual, Second Edition, Cold Spring Harbor, N.Y.,
(1989), Ausubel, F. M. et al. (eds.) Current Protocols in Molecular
Biology, Greene Publishing Associates, (1989) and in U.S. Pat. No.
4,816,397 by Boss et al.
[0109] To express adalimumab (D2E7) or an adalimumab (D2E7)-related
antibody, DNA fragments encoding the light and heavy chain variable
regions are first obtained. These DNAs can be obtained by
amplification and modification of germline light and heavy chain
variable sequences using the polymerase chain reaction (PCR).
Germline DNA sequences for human heavy and light chain variable
region genes are known in the art (see e.g., the "Vbase" human
germline sequence database; see also Kabat, E. A., et al. (1991)
Sequences of Proteins of Immunological Interest, Fifth Edition,
U.S. Department of Health and Human Services, NIH Publication No.
91-3242; Tomlinson, I. M., et al. (1992) "The Repertoire of Human
Germline V.sub.H Sequences Reveals about Fifty Groups of V.sub.H
Segments with Different Hypervariable Loops" J. Mol. Biol.
227:776-798; and Cox, J. P. L. et al. (1994) "A Directory of Human
Germ-line V.sub.78 Segments Reveals a Strong Bias in their Usage"
Eur. J. Immunol. 24:827-836; the contents of each of which are
expressly incorporated herein by reference). To obtain a DNA
fragment encoding the heavy chain variable region of D2E7, or a
D2E7-related antibody, a member of the V.sub.H3 family of human
germline VH genes is amplified by standard PCR. Most preferably,
the DP-31 VH germline sequence is amplified. To obtain a DNA
fragment encoding the light chain variable region of D2E7, or a
D2E7-related antibody, a member of the V.sub..kappa.I family of
human germline VL genes is amplified by standard PCR. Most
preferably, the A20 VL germline sequence is amplified. PCR primers
suitable for use in amplifying the DP-31 germline VH and A20
germline VL sequences can be designed based on the nucleotide
sequences disclosed in the references cited supra, using standard
methods.
[0110] Once the germline VH and VL fragments are obtained, these
sequences can be mutated to encode the D2E7 or D2E7-related amino
acid sequences disclosed herein. The amino acid sequences encoded
by the germline VH and VL DNA sequences are first compared to the
D2E7 or D2E7-related VH and VL amino acid sequences to identify
amino acid residues in the D2E7 or D2E7-related sequence that
differ from germline. Then, the appropriate nucleotides of the
germline DNA sequences are mutated such that the mutated germline
sequence encodes the D2E7 or D2E7-related amino acid sequence,
using the genetic code to determine which nucleotide changes should
be made. Mutagenesis of the germline sequences is carried out by
standard methods, such as PCR-mediated mutagenesis (in which the
mutated nucleotides are incorporated into the PCR primers such that
the PCR product contains the mutations) or site-directed
mutagenesis.
[0111] Moreover, it should be noted that if the "germline"
sequences obtained by PCR amplification encode amino acid
differences in the framework regions from the true germline
configuration (i.e., differences in the amplified sequence as
compared to the true germline sequence, for example as a result of
somatic mutation), it may be desirable to change these amino acid
differences back to the true germline sequences (i.e.,
"backmutation" of framework residues to the germline
configuration).
[0112] Once DNA fragments encoding D2E7 or D2E7-related VH and VL
segments are obtained (by amplification and mutagenesis of germline
VH and VL genes, as described above), these DNA fragments can be
further manipulated by standard recombinant DNA techniques, for
example to convert the variable region genes to full-length
antibody chain genes, to Fab fragment genes or to a scFv gene. In
these manipulations, a VL- or VH-encoding DNA fragment is
operatively linked to another DNA fragment encoding another
protein, such as an antibody constant region or a flexible linker.
The term "operatively linked", as used in this context, is intended
to mean that the two DNA fragments are joined such that the amino
acid sequences encoded by the two DNA fragments remain
in-frame.
[0113] The isolated DNA encoding the VH region can be converted to
a full-length heavy chain gene by operatively linking the
VH-encoding DNA to another DNA molecule encoding heavy chain
constant regions (CH1, CH2 and CH3). The sequences of human heavy
chain constant region genes are known in the art (see e.g., Kabat,
E. A., et al. (1991) Sequences of Proteins of Immunological
Interest, Fifth Edition, U.S. Department of Health and Human
Services, NIH Publication No. 91-3242) and DNA fragments
encompassing these regions can be obtained by standard PCR
amplification. The heavy chain constant region can be an IgG1,
IgG2, IgG3, IgG4, IgA, IgE, IgM or IgD constant region, but most
preferably is an IgG1 or IgG4 constant region. For a Fab fragment
heavy chain gene, the VH-encoding DNA can be operatively linked to
another DNA molecule encoding only the heavy chain CH1 constant
region.
[0114] The isolated DNA encoding the VL region can be converted to
a full-length light chain gene (as well as a Fab light chain gene)
by operatively linking the VL-encoding DNA to another DNA molecule
encoding the light chain constant region, CL. The sequences of
human light chain constant region genes are known in the art (see
e.g., Kabat, E. A., et al. (1991) Sequences of Proteins of
Immunological Interest, Fifth Edition, U.S. Department of Health
and Human Services, NIH Publication No. 91-3242) and DNA fragments
encompassing these regions can be obtained by standard PCR
amplification. The light chain constant region can be a kappa or
lambda constant region, but most preferably is a kappa constant
region.
[0115] To create a scFv gene, the VH- and VL-encoding DNA fragments
are operatively linked to another fragment encoding a flexible
linker, e.g., encoding the amino acid sequence
(Gly.sub.4-Ser).sub.3, such that the VH and VL sequences can be
expressed as a contiguous single-chain protein, with the VL and VH
regions joined by the flexible linker (see e.g., Bird et al. (1988)
Science 242:423-426; Huston et al. (1988) Proc. Natl. Acad. Sci.
USA 85:5879-5883; McCafferty et al., Nature (1990)
348:552-554).
[0116] To express the antibodies, or antibody portions used in the
invention, DNAs encoding partial or full-length light and heavy
chains, obtained as described above, are inserted into expression
vectors such that the genes are operatively linked to
transcriptional and translational control sequences. In this
context, the term "operatively linked" is intended to mean that an
antibody gene is ligated into a vector such that transcriptional
and translational control sequences within the vector serve their
intended function of regulating the transcription and translation
of the antibody gene. The expression vector and expression control
sequences are chosen to be compatible with the expression host cell
used. The antibody light chain gene and the antibody heavy chain
gene can be inserted into separate vector or, more typically, both
genes are inserted into the same expression vector. The antibody
genes are inserted into the expression vector by standard methods
(e.g., ligation of complementary restriction sites on the antibody
gene fragment and vector, or blunt end ligation if no restriction
sites are present). Prior to insertion of the D2E7 or D2E7-related
light or heavy chain sequences, the expression vector may already
carry antibody constant region sequences. For example, one approach
to converting the D2E7 or D2E7-related VH and VL sequences to
full-length antibody genes is to insert them into expression
vectors already encoding heavy chain constant and light chain
constant regions, respectively, such that the VH segment is
operatively linked to the CH segment(s) within the vector and the
VL segment is operatively linked to the CL segment within the
vector. Additionally or alternatively, the recombinant expression
vector can encode a signal peptide that facilitates secretion of
the antibody chain from a host cell. The antibody chain gene can be
cloned into the vector such that the signal peptide is linked
in-frame to the amino terminus of the antibody chain gene. The
signal peptide can be an immunoglobulin signal peptide or a
heterologous signal peptide (i.e., a signal peptide from a
non-immunoglobulin protein).
[0117] In addition to the antibody chain genes, the recombinant
expression vectors of the invention carry regulatory sequences that
control the expression of the antibody chain genes in a host cell.
The term "regulatory sequence" is intended to include promoters,
enhancers and other expression control elements (e.g.,
polyadenylation signals) that control the transcription or
translation of the antibody chain genes. Such regulatory sequences
are described, for example, in Goeddel; Gene Expression Technology:
Methods in Enzymology 185, Academic Press, San Diego, Calif.
(1990). It will be appreciated by those skilled in the art that the
design of the expression vector, including the selection of
regulatory sequences may depend on such factors as the choice of
the host cell to be transformed, the level of expression of protein
desired, etc. Preferred regulatory sequences for mammalian host
cell expression include viral elements that direct high levels of
protein expression in mammalian cells, such as promoters and/or
enhancers derived from cytomegalovirus (CMV) (such as the CMV
promoter/enhancer), Simian Virus 40 (SV40) (such as the SV40
promoter/enhancer), adenovirus, (e.g., the adenovirus major late
promoter (AdMLP)) and polyoma. For further description of viral
regulatory elements, and sequences thereof, see e.g., U.S. Pat. No.
5,168,062 by Stinski, U.S. Pat. No. 4,510,245 by Bell et al. and
U.S. Pat. No. 4,968,615 by Schaffner et al.
[0118] In addition to the antibody chain genes and regulatory
sequences, the recombinant expression vectors used in the invention
may carry additional sequences, such as sequences that regulate
replication of the vector in host cells (e.g., origins of
replication) and selectable marker genes. The selectable marker
gene facilitates selection of host cells into which the vector has
been introduced (see e.g., U.S. Pat. Nos. 4,399,216, 4,634,665 and
5,179,017, all by Axel et al.). For example, typically the
selectable marker gene confers resistance to drugs, such as G418,
hygromycin or methotrexate, on a host cell into which the vector
has been introduced. Preferred selectable marker genes include the
dihydrofolate reductase (DHFR) gene (for use in dhfr-host cells
with methotrexate selection/amplification) and the neo gene (for
G418 selection).
[0119] For expression of the light and heavy chains, the expression
vector(s) encoding the heavy and light chains is transfected into a
host cell by standard techniques. The various forms of the term
"transfection" are intended to encompass a wide variety of
techniques commonly used for the introduction of exogenous DNA into
a prokaryotic or eukaryotic host cell, e.g., electroporation,
calcium-phosphate precipitation, DEAE-dextran transfection and the
like. Although it is theoretically possible to express the
antibodies of the invention in either prokaryotic or eukaryotic
host cells, expression of antibodies in eukaryotic cells, and most
preferably mammalian host cells, is the most preferred because such
eukaryotic cells, and in particular mammalian cells, are more
likely than prokaryotic cells to assemble and secrete a properly
folded and immunologically active antibody. Prokaryotic expression
of antibody genes has been reported to be ineffective for
production of high yields of active antibody (Boss, M. A. and Wood,
C. R. (1985) Immunology Today 6:12-13).
[0120] Preferred mammalian host cells for expressing the
recombinant antibodies of the invention include Chinese Hamster
Ovary (CHO cells) (including dhfr-CHO cells, described in Urlaub
and Chasin, (1980) Proc. Natl. Acad. Sci. USA 77:4216-4220, used
with a DHFR selectable marker, e.g., as described in R. J. Kaufman
and P. A. Sharp (1982) Mol. Biol. 159:601-621), NSO myeloma cells,
COS cells and SP2 cells. When recombinant expression vectors
encoding antibody genes are introduced into mammalian host cells,
the antibodies are produced by culturing the host cells for a
period of time sufficient to allow for expression of the antibody
in the host cells or, more preferably, secretion of the antibody
into the culture medium in which the host cells are grown.
Antibodies can be recovered from the culture medium using standard
protein purification methods.
[0121] Host cells can also be used to produce portions of intact
antibodies, such as Fab fragments or scFv molecules. It is
understood that variations on the above procedure are within the
scope of the present invention. For example, it may be desirable to
transfect a host cell with DNA encoding either the light chain or
the heavy chain (but not both) of an antibody of this invention.
Recombinant DNA technology may also be used to remove some or all
of the DNA encoding either or both of the light and heavy chains
that is not necessary for binding to hTNF.alpha.. The molecules
expressed from such truncated DNA molecules are also encompassed by
the antibodies of the invention. In addition, bifunctional
antibodies may be produced in which one heavy and one light chain
are an antibody of the invention and the other heavy and light
chain are specific for an antigen other than hTNF.alpha. by
crosslinking an antibody of the invention to a second antibody by
standard chemical crosslinking methods.
[0122] In a preferred system for recombinant expression of an
antibody, or antigen-binding portion thereof, of the invention, a
recombinant expression vector encoding both the antibody heavy
chain and the antibody light chain is introduced into dhfr-CHO
cells by calcium phosphate-mediated transfection. Within the
recombinant expression vector, the antibody heavy and light chain
genes are each operatively linked to CMV enhancer/AdMLP promoter
regulatory elements to drive high levels of transcription of the
genes. The recombinant expression vector also carries a DHFR gene,
which allows for selection of CHO cells that have been transfected
with the vector using methotrexate selection/amplification. The
selected transformant host cells are culture to allow for
expression of the antibody heavy and light chains and intact
antibody is recovered from the culture medium. Standard molecular
biology techniques are used to prepare the recombinant expression
vector, transfect the host cells, select for transformants, culture
the host cells and recover the antibody from the culture
medium.
[0123] In view of the foregoing, nucleic acid, vector and host cell
compositions that can be used for recombinant expression of the
antibodies and antibody portions used in the invention include
nucleic acids, and vectors comprising said nucleic acids,
comprising the human TNF.alpha. antibody adalimumab (D2E7). The
nucleotide sequence encoding the D2E7 light chain variable region
is shown in SEQ ID NO: 36. The CDR1 domain of the LCVR encompasses
nucleotides 70-102, the CDR2 domain encompasses nucleotides 148-168
and the CDR3 domain encompasses nucleotides 265-291. The nucleotide
sequence encoding the D2E7 heavy chain variable region is shown in
SEQ ID NO: 37. The CDR1 domain of the HCVR encompasses nucleotides
91-105, the CDR2 domain encompasses nucleotides 148-198 and the
CDR3 domain encompasses nucleotides 295-330. It will be appreciated
by the skilled artisan that nucleotide sequences encoding
D2E7-related antibodies, or portions thereof (e.g., a CDR domain,
such as a CDR3 domain), can be derived from the nucleotide
sequences encoding the D2E7 LCVR and HCVR using the genetic code
and standard molecular biology techniques.
[0124] Recombinant human antibodies of the invention in addition to
D2E7 or an antigen binding portion thereof, or D2E7-related
antibodies disclosed herein can be isolated by screening of a
recombinant combinatorial antibody library, preferably a scFv phage
display library, prepared using human VL and VH cDNAs prepared from
mRNA derived from human lymphocytes. Methodologies for preparing
and screening such libraries are known in the art. In addition to
commercially available kits for generating phage display libraries
(e.g., the Pharmacia Recombinant Phage Antibody System, catalog no.
27-9400-01; and the Stratagene SurfZAP.TM. phage display kit,
catalog no. 240612), examples of methods and reagents particularly
amenable for use in generating and screening antibody display
libraries can be found in, for example, Ladner et al. U.S. Pat. No.
5,223,409; Kang et al. PCT Publication No. WO 92/18619; Dower et
al. PCT Publication No. WO 91/17271; Winter et al. PCT Publication
No. WO 92/20791; Markland et al. PCT Publication No. WO 92/15679;
Breitling et al. PCT Publication No. WO 93/01288; McCafferty et al.
PCT Publication No. WO 92/01047; Garrard et al. PCT Publication No.
WO 92/09690; Fuchs et al. (1991) Bio/Technology 9:1370-1372; Hay et
al. (1992) Hum Antibod Hybridomas 3:81-65; Huse et al. (1989)
Science 246:1275-1281; McCafferty et al., Nature (1990)
348:552-554; Griffiths et al. (1993) EMBO J. 12:725-734; Hawkins et
al. (1992) J Mol Biol 226:889-896; Clackson et al. (1991) Nature
352:624-628; Gram et al. (1992) PNAS 89:3576-3580; Garrard et al.
(1991) Bio/Technology 9:1373-1377; Hoogenboom et al. (1991) Nuc
Acid Res 19:4133-4137; and Barbas et al. (1991) PNAS
88:7978-7982.
[0125] In a preferred embodiment, to isolate human antibodies with
high affinity and a low off rate constant for hTNF.alpha., a murine
anti-hTNF.alpha. antibody having high affinity and a low off rate
constant for hTNF.alpha. (e.g., MAK 195, the hybridoma for which
has deposit number ECACC 87 050801) is first used to select human
heavy and light chain sequences having similar binding activity
toward hTNF.alpha., using the epitope imprinting methods described
in Hoogenboom et al., PCT Publication No. WO 93/06213. The antibody
libraries used in this method are preferably scFv libraries
prepared and screened as described in McCafferty et al., PCT
Publication No. WO 92/01047, McCafferty et al., Nature (1990)
348:552-554; and Griffiths et al., (1993) EMBO J. 12:725-734. The
scFv antibody libraries preferably are screened using recombinant
human TNF.alpha. as the antigen.
[0126] Once initial human VL and VH segments are selected, "mix and
match" experiments, in which different pairs of the initially
selected VL and VH segments are screened for hTNF.alpha. binding,
are performed to select preferred VL/VH pair combinations.
Additionally, to further improve the affinity and/or lower the off
rate constant for hTNF.alpha. binding, the VL and VH segments of
the preferred VL/VH pair(s) can be randomly mutated, preferably
within the CDR3 region of VH and/or VL, in a process analogous to
the in vivo somatic mutation process responsible for affinity
maturation of antibodies during a natural immune response. This in
vitro affinity maturation can be accomplished by amplifying VH and
VL regions using PCR primers complimentary to the VH CDR3 or VL
CDR3, respectively, which primers have been "spiked" with a random
mixture of the four nucleotide bases at certain positions such that
the resultant PCR products encode VH and VL segments into which
random mutations have been introduced into the VH and/or VL CDR3
regions. These randomly mutated VH and VL segments can be
rescreened for binding to hTNF.alpha. and sequences that exhibit
high affinity and a low off rate for hTNF.alpha. binding can be
selected.
[0127] Following screening and isolation of an anti-hTNF.alpha.
antibody of the invention from a recombinant immunoglobulin display
library, nucleic acid encoding the selected antibody can be
recovered from the display package (e.g., from the phage genome)
and subcloned into other expression vectors by standard recombinant
DNA techniques. If desired, the nucleic acid can be further
manipulated to create other antibody forms of the invention (e.g.,
linked to nucleic acid encoding additional immunoglobulin domains,
such as additional constant regions). To express a recombinant
human antibody isolated by screening of a combinatorial library,
the DNA encoding the antibody is cloned into a recombinant
expression vector and introduced into a mammalian host cells, as
described in further detail in above.
[0128] Methods of isolating human neutralizing antibodies with high
affinity and a low off rate constant for hTNF.alpha. are described
in U.S. Pat. Nos. 6,090,382, 6,258,562, and 6,509,015, each of
which is incorporated by reference herein.
[0129] Antibodies, antibody-portions, and other TNF.alpha.
inhibitors for use in the methods of the invention, can be
incorporated into pharmaceutical compositions suitable for
administration to a subject. Typically, the pharmaceutical
composition comprises an antibody, antibody portion, or other
TNF.alpha. inhibitor, and a pharmaceutically acceptable carrier. As
used herein, "pharmaceutically acceptable carrier" includes any and
all solvents, dispersion media, coatings, antibacterial and
antifungal agents, isotonic and absorption delaying agents, and the
like that are physiologically compatible. Examples of
pharmaceutically acceptable carriers include one or more of water,
saline, phosphate buffered saline, dextrose, glycerol, ethanol and
the like, as well as combinations thereof. In many cases, it is
preferable to include isotonic agents, for example, sugars,
polyalcohols such as mannitol, sorbitol, or sodium chloride in the
composition. Pharmaceutically acceptable carriers may further
comprise minor amounts of auxiliary substances such as wetting or
emulsifying agents, preservatives or buffers, which enhance the
shelf life or effectiveness of the antibody, antibody portion, or
other TNF.alpha. inhibitor.
[0130] The compositions for use in the methods and compositions of
the invention may be in a variety of forms. These include, for
example, liquid, semi-solid and solid dosage forms, such as liquid
solutions (e.g., injectable and infusible solutions), dispersions
or suspensions, tablets, pills, powders, liposomes and
suppositories. The preferred form depends on the intended mode of
administration and therapeutic application. Typical preferred
compositions are in the form of injectable or infusible solutions,
such as compositions similar to those used for passive immunization
of humans with other antibodies or other TNF.alpha. inhibitors. The
preferred mode of administration is parenteral (e.g., intravenous,
subcutaneous, intraperitoneal, intramuscular). In a preferred
embodiment, the antibody or other TNF.alpha. inhibitor is
administered by intravenous infusion or injection. In another
preferred embodiment, the antibody or other TNF.alpha. inhibitor is
administered by intramuscular or subcutaneous injection.
[0131] Therapeutic compositions typically must be sterile and
stable under the conditions of manufacture and storage. The
composition can be formulated as a solution, microemulsion,
dispersion, liposome, or other ordered structure suitable to high
drug concentration. Sterile injectable solutions can be prepared by
incorporating the active compound (i.e., antibody, antibody
portion, or other TNF.alpha. inhibitor) in the required amount in
an appropriate solvent with one or a combination of ingredients
enumerated above, as required, followed by filtered sterilization.
Generally, dispersions are prepared by incorporating the active
compound into a sterile vehicle that contains a basic dispersion
medium and the required other ingredients from those enumerated
above. In the case of sterile powders for the preparation of
sterile injectable solutions, the preferred methods of preparation
are vacuum drying and freeze-drying that yields a powder of the
active ingredient plus any additional desired ingredient from a
previously sterile-filtered solution thereof. The proper fluidity
of a solution can be maintained, for example, by the use of a
coating such as lecithin, by the maintenance of the required
particle size in the case of dispersion and by the use of
surfactants. Prolonged absorption of injectable compositions can be
brought about by including in the composition an agent that delays
absorption, for example, monostearate salts and gelatin.
[0132] In one embodiment, the invention includes pharmaceutical
compositions comprising an effective TNF.alpha. inhibitor and a
pharmaceutically acceptable carrier, wherein the effective
TNF.alpha. inhibitor may be used to treat ankylosing
spondylitis.
[0133] In one embodiment, the antibody or antibody portion for use
in the methods of the invention is incorporated into a
pharmaceutical formulation as described in PCT/IB03/04502 and U.S.
Appln. No. 20040033228, incorporated by reference herein. This
formulation includes a concentration 50 mg/ml of the antibody D2E7
(adalimumab), wherein one pre-filled syringe contains 40 mg of
antibody for subcutaneous injection.
[0134] The antibodies, antibody-portions, and other TNF.alpha.
inhibitors of the present invention can be administered by a
variety of methods known in the art, although for many therapeutic
applications, the preferred route/mode of administration is
parenteral, e.g., subcutaneous injection. In another embodiment,
administration is via intravenous injection or infusion.
[0135] As will be appreciated by the skilled artisan, the route
and/or mode of administration will vary depending upon the desired
results. In certain embodiments, the active compound may be
prepared with a carrier that will protect the compound against
rapid release, such as a controlled release formulation, including
implants, transdermal patches, and microencapsulated delivery
systems. Biodegradable, biocompatible polymers can be used, such as
ethylene vinyl acetate, polyanhydrides, polyglycolic acid,
collagen, polyorthoesters, and polylactic acid. Many methods for
the preparation of such formulations are patented or generally
known to those skilled in the art. See, e.g., Sustained and
Controlled Release Drug Delivery Systems, Robinson, ed., Dekker,
Inc., New York, 1978.
[0136] In one embodiment, the TNF.alpha. antibodies and inhibitors
used in the invention are delivered to a subject subcutaneously. In
one embodiment, the subject administers the TNF.alpha. inhibitor,
including, but not limited to, TNF.alpha. antibody, or
antigen-binding portion thereof, to himself/herself.
[0137] The TNF.alpha. antibodies and inhibitors used in the
invention may also be administered in the form of protein crystal
formulations which include a combination of protein crystals
encapsulated within a polymeric carrier to form coated particles.
The coated particles of the protein crystal formulation may have a
spherical morphology and be microspheres of up to 500 micro meters
in diameter or they may have some other morphology and be
microparticulates. The enhanced concentration of protein crystals
allows the antibody of the invention to be delivered
subcutaneously. In one embodiment, the TNF.alpha. antibodies of the
invention are delivered via a protein delivery system, wherein one
or more of a protein crystal formulation or composition, is
administered to a subject with a TNF.alpha.-related disorder.
Compositions and methods of preparing stabilized formulations of
whole antibody crystals or antibody fragment crystals are also
described in WO 02/072636, which is incorporated by reference
herein. In one embodiment, a formulation comprising the
crystallized antibody fragments described in PCT/IB03/04502 and
U.S. Appln. No. 20040033228, incorporated by reference herein, are
used to treat ankylosing spondylitis using the treatment methods of
the invention.
[0138] In certain embodiments, an antibody, antibody portion, or
other TNF.alpha. inhibitor of the invention may be orally
administered, for example, with an inert diluent or an assimilable
edible carrier. The compound (and other ingredients, if desired)
may also be enclosed in a hard or soft shell gelatin capsule,
compressed into tablets, or incorporated directly into the
subject's diet. For oral therapeutic administration, the compounds
may be incorporated with excipients and used in the form of
ingestible tablets, buccal tablets, troches, capsules, elixirs,
suspensions, syrups, wafers, and the like. To administer a compound
of the invention by other than parenteral administration, it may be
necessary to coat the compound with, or co-administer the compound
with, a material to prevent its inactivation.
[0139] Supplementary active compounds can also be incorporated into
the compositions. In certain embodiments, an antibody or antibody
portion for use in the methods of the invention is coformulated
with and/or coadministered with one or more additional therapeutic
agents, including an ankylosing spondylitis inhibitor or
antagonist. For example, an anti-hTNF.alpha. antibody or antibody
portion of the invention may be coformulated and/or coadministered
with one or more additional antibodies that bind other targets
associated with TNF.alpha. related disorders (e.g., antibodies that
bind other cytokines or that bind cell surface molecules), one or
more cytokines, soluble TNF.alpha. receptor (see e.g., PCT
Publication No. WO 94/06476) and/or one or more chemical agents
that inhibit hTNF.alpha. production or activity (such as
cyclohexane-ylidene derivatives as described in PCT Publication No.
WO 93/19751) or any combination thereof. Furthermore, one or more
antibodies of the invention may be used in combination with two or
more of the foregoing therapeutic agents. Such combination
therapies may advantageously utilize lower dosages of the
administered therapeutic agents, thus avoiding possible side
effects, complications or low level of response by the patient
associated with the various monotherapies.
[0140] The pharmaceutical compositions of the invention may include
a "therapeutically effective amount" or a "prophylactically
effective amount" of an antibody or antibody portion of the
invention. A "therapeutically effective amount" refers to an amount
effective, at dosages and for periods of time necessary, to achieve
the desired therapeutic result. A therapeutically effective amount
of the antibody, antibody portion, or other TNF.alpha. inhibitor
may vary according to factors such as the disease state, age, sex,
and weight of the individual, and the ability of the antibody,
antibody portion, other TNF.alpha. inhibitor to elicit a desired
response in the individual. A therapeutically effective amount is
also one in which any toxic or detrimental effects of the antibody,
antibody portion, or other TNF.alpha. inhibitor are outweighed by
the therapeutically beneficial effects. A "prophylactically
effective amount" refers to an amount effective, at dosages and for
periods of time necessary, to achieve the desired prophylactic
result. Typically, since a prophylactic dose is used in subjects
prior to or at an earlier stage of disease, the prophylactically
effective amount will be less than the therapeutically effective
amount.
[0141] Additional description regarding methods and uses of the
invention comprising administration of a TNF.alpha. inhibitor are
described in Part III of this specification, as well as the below
examples.
[0142] The invention also pertains to packaged pharmaceutical
compositions or kits for administering the anti-TNF antibodies of
the invention for the treatment of ankylosing spondylitis. In one
embodiment of the invention, the kit comprises a TNF.alpha.
inhibitor, such as an antibody and instructions for administration
of the TNF.alpha. inhibitor for treatment of ankylosing
spondylitis. The instructions may describe how, e.g.,
subcutaneously, and when, e.g., at week 0, week 2, week 4, etc.,
the different doses of TNF.alpha. inhibitor shall be administered
to a subject for treatment.
[0143] Another aspect of the invention pertains to kits containing
a pharmaceutical composition comprising a TNF.alpha. inhibitor,
such as an antibody, and a pharmaceutically acceptable carrier and
one or more pharmaceutical compositions each comprising an
additional therapeutic agent useful for treating ankylosing
spondylitis, and a pharmaceutically acceptable carrier.
Alternatively, the kit comprises a single pharmaceutical
composition comprising an anti-TNF.alpha. antibody, one or more
drugs useful for treating ankylosing spondylitis, and a
pharmaceutically acceptable carrier. The instructions may describe
how, e.g., subcutaneously, and when, e.g., at week 0, week 2, week
4, etc., the different doses of TNF.alpha. inhibitor and/or the
additional therapeutic agent shall be administered to a subject for
treatment.
[0144] The kit may contain instructions for dosing of the
pharmaceutical compositions for the treatment of ankylosing
spondylitis. Additional description regarding articles of
manufacture of the invention are described in subsection III.
[0145] The package or kit alternatively can contain the TNF.alpha.
inhibitor and it can be promoted for use, either within the package
or through accompanying information, for the uses or treatment of
the disorders described herein. The packaged pharmaceuticals or
kits further can include a second agent (as described herein)
packaged with or copromoted with instructions for using the second
agent with a first agent (as described herein).
III. Uses and Compositions for Treating Ankylosing Spondylitis
[0146] Ankylosing spondylitis (AS) is a chronic rheumatic disease.
The sacroiliac joints are affected and, to a varying degree, the
spinal column. The disease may also involve the peripheral joints
and extra-articular structures. Patients commonly experience pain,
morning stiffness and disability, all which generally increase with
duration of disease. Systemic features, such as anorexia and
fatigue may also occur. In late disease, some patients develop
acute anterior uveitis, cardiovascular or pulmonary problems. Men
are more commonly affected than women, and, as with other
sponylarthritides, AS is associated with positivity for the HLA-B27
gene.
[0147] In one embodiment, the invention provides a method for
treating ankylosing spondylitis in a subject. The invention also
provides a method for achieving partial remission of a subject
having AS by administering a TNF.alpha. inhibitor.
[0148] In one embodiment, treatment of AS is achieved by
administering a TNF.alpha. inhibitor to a subject in accordance
with a biweekly dosing regimen. Biweekly dosing regimens can be
used to treat disorders in which TNF.alpha. activity is
detrimental, and are further described in U.S. application Ser. No.
10/163,657 (US 20030235585), incorporated by reference herein. The
TNF.alpha. inhibitor, including a TNF.alpha. antibody, or an
antigen-binding portion thereof, may be administered to the subject
on a biweekly dosing regimen for treatment of AS. In one
embodiment, biweekly dosing includes a dosing regimen wherein doses
of a TNF.alpha. inhibitor are administered to a subject every other
week beginning at week 0. In one embodiment, biweekly dosing
includes a dosing regimen where doses of a TNF.alpha. inhibitor are
administered to a subject every other week consecutively for a
given time period, e.g., 4 weeks, 8 weeks, 16, weeks, 24 weeks,
etc. Biweekly dosing is preferably administered parenterally,
including subcutaneously.
[0149] In one embodiment, the human TNF.alpha. antibody, or an
antigen-binding portion thereof, is administered in a dose of about
40 mg. In one embodiment, the human TNF.alpha. antibody, or an
antigen-binding portion thereof, is adalimumab.
[0150] The invention provides a method of decreasing pain and
fatigue in a subject having AS comprising administering a human
TNF.alpha. antibody, or antigen-binding portion thereof, to the
subject such that pain and fatigue are decreased. The invention
also includes use of a human TNF.alpha. antibody, or
antigen-binding portion thereof, in the manufacture of a medicament
for the treatment of pain and fatigue in a subject having AS.
[0151] The invention also provides methods for improving AS in a
subject based on indices used to measure the disease state. In one
embodiment, the invention provides a method for decreasing the
decrease in fatigue is determined by a decrease of at least about
1.9 in a BASDAI score of the subject. In one embodiment, the
decrease in fatigue is determined by a decrease of at least about
2.0 in a BASDAI score of the subject. Alternatively, improvements
in fatigue in a subject having AS may be determined using the
FACIT-F score, e.g., a meach change in FACIT score of about 7-8
following treatment of the subject with a TNF.alpha. inhibitor.
[0152] The invention also includes a method of inducing partial
remission of AS in a subject comprising administering a human
TNF.alpha. antibody, or antigen-binding portion thereof, to the
subject, such that partial remission of AS is induced. The
invention provides a use of a human TNF.alpha. antibody, or
antigen-binding portion thereof, in the manufacture of a medicament
for inducing partial remission of AS in a subject. In one
embodiment, the subject has a value of less than 20 on a scale of
0-100 in all four ASAS domains.
[0153] The invention provides uses and methods for treating certain
subpopulations of AS patients with a TNF.alpha. inhibitor. Also
included in the invention are methods for determining whether a
TNF.alpha. inhibitor, e.g., a TNF.alpha. antibody, or
antigen-binding portion thereof, is effective for treating a
certain subpopulation of AS patients. Thus, the invention also
includes a method of treating a subject who is a member of a
subpopulation of AS patients with a TNF.alpha. inhibitor which has
been identified as being an effective TNF.alpha. inhibitor for the
treatment of the given subpopulation. In one embodiment, the
methods of treatment described herein may be used to treat AS
subjects who have failed prior therapy with conventional drugs used
to treat AS. Examples of such conventional therapy include DMARD
therapy and NSAIDs therapy. Failure on a prior therapy can be
measured using any of the indices described herein, e.g., failure
to achieve an ASAS20 response.
[0154] In one embodiment, treatment of AS is achieved by
administering a human TNF.alpha. antibody, or an antigen-binding
portion thereof, to a subject having AS, wherein the human
TNF.alpha. antibody, or an antigen-binding portion thereof, is
administered on a biweekly dosing regimen.
[0155] Methods of treatment described herein may include
administration of a TNF.alpha. inhibitor to a subject to achieve a
therapeutic goal, e.g., improvement in ASAS domains, induction of
partial remission, ASAS2.0, ASAS40, ASAS50, ASAS70 response,
ASAS5/6 response, improvement in BASDAI score, BASDAI20 response,
BASDAI50 response, BASDAI 70 response Also included in the scope of
the invention are uses of a TNF.alpha. inhibitor in the manufacture
of a medicament to achieve a therapeutic goal, e.g., improvement in
ASAS domains, induction of partial remission, ASAS20, ASAS40,
ASAS50, ASAS70 response, ASAS5/6 response, improvement in BASDAI
score, BASDAI20 response, BASDAI50 response, BASDAI 70 response.
Thus, where methods are described herein, it is also intended to be
part of this invention that the use of the TNF.alpha. inhibitor in
the manufacture of a medicament for the purpose of the method is
also considered within the scope of the invention. Likewise, where
a use of a TNF.alpha. inhibitor in the manufacture of a medicament
for the purpose of achieving a therapeutic goal is described,
methods of treatment resulting in the therapeutic goal are also
intended to be part of the invention.
[0156] In one embodiment, the invention provides a method of
treating AS in a subject comprising administering a human
TNF.alpha. antibody, or antigen-binding portion thereof, e.g.,
adalimumab, to the subject at week 0 on a biweekly dosing regimen.
In one embodiment, the human TNF.alpha. antibody, or
antigen-binding portion thereof, is administered subcutaneously. In
one embodiment, AS is treated by administering a human TNF.alpha.
antibody, or antigen-binding portion thereof, on biweekly dosing
regimen for a minimum time period, e.g., at least about 12 weeks,
at least about 20, or at least about 24.
[0157] Dosage unit form as used herein refers to physically
discrete units suited as unitary dosages for the mammalian subjects
to be treated; each unit containing a predetermined quantity of
active compound calculated to produce the desired therapeutic
effect in association with the required pharmaceutical carrier. The
specification for the dosage unit forms of the invention are
dictated by and directly dependent on (a) the unique
characteristics of the active compound and the particular
therapeutic or prophylactic effect to be achieved, and (b) the
limitations inherent in the art of compounding such an active
compound for the treatment of sensitivity in individuals.
[0158] Dosage regimens described herein may be adjusted to provide
the optimum desired response, e.g., attaining partial remission of
AS, in consideration of the teachings herein. It is to be noted
that dosage values may vary with the type and severity of AS. It is
to be further understood that for any particular subject, specific
dosage regimens may be adjusted over time according to the
teachings of the specification and the individual need and the
professional judgment of the person administering or supervising
the administration of the compositions, and that dosage amounts and
ranges set forth herein are exemplary only and are not intended to
limit the scope or practice of the claimed invention.
Articles of Manufacture
[0159] The invention also provides a packaged pharmaceutical
composition wherein the TNF.alpha. inhibitor, e.g., TNF.alpha.
antibody, is packaged within a kit or an article of manufacture.
The kit or article of manufacture of the invention contains
materials useful for the treatment, including induction and/or
remission, prevention and/or diagnosis of AS. The kit or article of
manufacture comprises a container and a label or package insert or
printed material on or associated with the container which provides
information regarding use of the TNF.alpha. inhibitor, e.g., a
TNF.alpha. antibody, for the treatment of AS.
[0160] A kit or an article of manufacture refers to a packaged
product comprising components with which to administer a TNF.alpha.
inhibitor for treatment of AS. The kit preferably comprises a box
or container that holds the components of the kit. The box or
container is affixed with a label or a Food and Drug Administration
approved label, including a protocol for administering the
TNF.alpha. inhibitor. The box or container holds components of the
invention which are preferably contained within plastic,
polyethylene, polypropylene, ethylene, or propylene vessels. The
vessels can be capped-tubes or bottles. The kit can also include
instructions for administering the TNF.alpha. antibody of the
invention. In one embodiment the kit of the invention includes the
formulation comprising the human antibody adalimumab (or D2E7), as
described in PCT/IB03/04502 and U.S. application Ser. No.
10/222,140, incorporated by reference herein.
[0161] The term "package insert" is used to refer to instructions
customarily included in commercial packages of therapeutic
products, that contain information about the indications, usage,
dosage, administration, contraindications and/or warnings
concerning the use of such therapeutic products.
[0162] Suitable containers for the TNF.alpha. inhibitor, e.g., a
TNF.alpha. antibody, include, for example, bottles, vials,
syringes, pens, etc. The containers may be formed from a variety of
materials such as glass or plastic. The container holds a
composition which is by itself or when combined with another
composition effective for treating, preventing and/or diagnosing
the condition and may have a sterile access port.
[0163] In one embodiment, the article of manufacture comprises a
TNF.alpha. inhibitor, e.g., a TNF.alpha. antibody, and a label
which indicates to a subject who will be administering the
TNF.alpha. inhibitor about using the TNF.alpha. inhibitor for the
treatment of AS. The label may be anywhere within or on the article
of manufacture. In one embodiment, the article of manufacture
comprises a container, such as a box, which comprises the
TNF.alpha. inhibitor and a package insert or label providing
information pertaining to use of the TNF.alpha. inhibitor for the
treatment of AS. In another embodiment, the information is printed
on a label which is on the outside of the article of manufacture,
in a position which is visible to prospective purchasers.
[0164] In one embodiment, the package insert of the invention
informs a reader, including a subject, e.g., a purchaser, who will
be administering the TNF.alpha. inhibitor for treatment, that the
TNF.alpha. inhibitor, e.g., a TNF.alpha. antibody such as
adalimumab, is an indicated treatment of AS, including of
moderately to severely active disease in adult patients.
[0165] In one embodiment, the article of manufacture of the
invention comprises a human TNF.alpha. antibody, or antigen-binding
portion thereof, and a package insert comprising instructions for
administering the human TNF.alpha. antibody, or antigen-binding
portion thereof, to a human subject for the treatment of adults
with moderate to severe active ankylosing spondylitis who have had
an inadequate response to conventional therapy.
[0166] The package insert may describe certain patient populations
who may respond favorably to the TNF.alpha. inhibitor within the
article of manufacture. For example, the package insert may
indicate that the TNF.alpha. antibody, e.g., adalimumab, may be
used to treat AS in patients who have had an inadequate response to
conventional therapy, e.g., DMARD or NSAID therapy. In one
embodiment, the invention provides an article of manufacture
comprising a human TNF.alpha. antibody, or antigen-binding portion
thereof, and a package insert which indicates that the human
TNF.alpha. antibody, or antigen-binding portion thereof, is
indicated for the treatment of adults with moderate to severe
active ankylosing spondylitis who have had an inadequate response
to conventional therapy.
[0167] In one embodiment, the package insert of the invention
describes certain therapeutic benefits of the TNF.alpha. antibody,
e.g., adalimumab, including specific symptoms of AS which may be
reduced by using the TNF.alpha. antibody, e.g., adalimumab. It
should be noted that the package insert may also contain
information pertaining to other disorders which are treatable using
the TNF.alpha. antibody, e.g., adalimumab.
[0168] In another embodiment, the package insert of the invention
describes the dose and administration of adalimumab, for the
treatment of AS. The label may indicate that the recommended dose
for the treatment of AS with adalimumab is 40 mg administered every
other week. In one embodiment, the package insert of the invention
indicates that adalimumab is administered by subcutaneous
injection.
[0169] The package insert of the invention may also provide
information to subjects who will be receiving adalimumab regarding
combination uses for both safety and efficacy purposes. The package
insert of the invention may contain warnings and precautions
regarding the use of the TNF.alpha. inhibitor, e.g., a TNF.alpha.
antibody such as adalimumab.
[0170] The label of the invention may further contain information
regarding the use of the TNF.alpha. inhibitor, e.g., a TNF.alpha.
antibody such as adalimumab, in clinical studies for AS. In one
embodiment, the label of the invention describes the studies
described herein as the Examples, either as a whole or in
portion.
[0171] In one embodiment of the invention, the kit comprises a
TNF.alpha. inhibitor, such as an antibody, an second pharmaceutical
composition comprising an additional therapeutic agent, and
instructions for administration of both agents for the treatment of
AS. The instructions may describe how, e.g., subcutaneously, and
when, e.g., at week 0, week 2, and biweekly thereafter, doses of
TNF.alpha. antibody and/or the additional therapeutic agent shall
be administered to a subject for treatment.
[0172] Another aspect of the invention pertains to kits containing
a pharmaceutical composition comprising an anti-TNF.alpha. antibody
and a pharmaceutically acceptable carrier and one or more
additional pharmaceutical compositions each comprising a drug
useful for treating a TNF.alpha. related disorder and a
pharmaceutically acceptable carrier. Alternatively, the kit
comprises a single pharmaceutical composition comprising an
anti-TNF.alpha. antibody, one or more drugs useful for treating a
TNF.alpha. related disorder and a pharmaceutically acceptable
carrier. The kits further contain instructions for dosing of the
pharmaceutical compositions for the treatment of a TNF.alpha.
related disorder.
[0173] The package or kit alternatively may contain the TNF.alpha.
inhibitor and it may be promoted for use, either within the package
or through accompanying information, for the uses or treatment of
the disorders described herein. The packaged pharmaceuticals or
kits further can include a second agent (as described herein)
packaged with or copromoted with instructions for using the second
agent with a first agent (as described herein).
Additional Therapeutic Agents
[0174] Methods, uses, and compositions of the invention also
include combinations of TNF.alpha. inhibitors, including
antibodies, and other therapeutic agents. TNF.alpha. inhibitors,
including antibodies, or antigen binding portions thereof, can be
used alone or in combination with additional agents to treat AS. It
should be understood that antibodies, or antigen binding portion
thereof, can be used alone or in combination with an additional
agent, e.g., a therapeutic agent, said additional agent being
selected by the skilled artisan for its intended purpose. For
example, the additional agent can be a therapeutic agent
art-recognized as being useful to treat the disease or condition
being treated by the antibody of the present invention. The
additional agent also can be an agent that imparts a beneficial
attribute to the therapeutic composition e.g., an agent which
affects the viscosity of the composition.
[0175] It should further be understood that the combinations which
are to be included within this invention are those combinations
useful for their intended purpose. The agents set forth below are
illustrative for purposes and not intended to be limited. The
combinations, which are part of this invention, can be the
antibodies of the present invention and at least one additional
agent selected from the lists below. The combination can also
include more than one additional agent, e.g., two or three
additional agents if the combination is such that the formed
composition can perform its intended function.
[0176] TNF.alpha. inhibitors described herein may be used in
combination with additional therapeutic agents such as a Disease
Modifying Anti-Rheumatic Drug (DMARD) or a Nonsteroidal
Antiinflammatory Drug (NSAID) or a steroid or any combination
thereof. Preferred examples of a DMARD are hydroxychloroquine,
leflunomide, methotrexate, parenteral gold, oral gold and
sulfasalazine. Preferred examples of non-steroidal
anti-inflammatory drug(s) also referred to as NSAIDS include drugs
like ibuprofen. Other preferred combinations are corticosteroids
including prednisolone; the well known side effects of steroid use
can be reduced or even eliminated by tapering the steroid dose
required when treating patients in combination with the
anti-TNF.alpha. antibodies of this invention. Non-limiting examples
of therapeutic agents for rheumatoid arthritis with which an
antibody, or antibody portion, of the invention can be combined
include the following: cytokine suppressive anti-inflammatory
drug(s) (CSAIDs); antibodies to or antagonists of other human
cytokines or growth factors, for example, TNF, LT, IL-1, IL-2,
IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-15, IL-16, IL-18, IL-21,
IL-23, interferons, EMAP-II, GM-CSF, FGF, and PDGF. Antibodies of
the invention, or antigen binding portions thereof, can be combined
with antibodies to cell surface molecules such as CD2, CD3, CD4,
CD8, CD25, CD28, CD30, CD40, CD45, CD69, CD80 (B7.1), CD86 (B7.2),
CD90, CTLA or their ligands including CD154 (gp39 or CD40L).
[0177] Preferred combinations of therapeutic agents may interfere
at different points in the autoimmune and subsequent inflammatory
cascade; preferred examples include TNF antagonists/inhibitors such
as soluble p55 or p75 TNF receptors, derivatives, thereof,
(p75TNFR1gG (Enbrel.TM.) or p55TNFR1gG (Lenercept), chimeric,
humanized or human TNF antibodies, or a fragment thereof, including
infliximab (Remicade.RTM., Johnson and Johnson; described in U.S.
Pat. No. 5,656,272, incorporated by reference herein), CDP571 (a
humanized monoclonal anti-TNF-alpha IgG4 antibody), CDP 870 (a
humanized monoclonal anti-TNF-alpha antibody fragment), an anti-TNF
dAb (Peptech), CNTO 148 (golimumab; Medarex and Centocor, see WO
02/12502), and adalimumab (Humira.RTM. Abbott Laboratories, a human
anti-TNF mAb, described in U.S. Pat. No. 6,090,382 as D2E7).
Additional TNF antibodies which can be used in the invention are
described in U.S. Pat. Nos. 6,593,458; 6,498,237; 6,451,983; and
6,448,380, each of which is incorporated by reference herein. Other
combinations including TNF.alpha. converting enzyme (TACE)
inhibitors; IL-1 inhibitors (Interleukin-1-converting enzyme
inhibitors, IL-1RA etc.) may be effective for the same reason.
Other combinations include the IL-6 antibody tocilizumab (Actemra).
Other preferred combinations include Interleukin 11. Yet another
preferred combination are other key players of the autoimmune
response which may act parallel to, dependent on or in concert with
TNF.alpha. function; especially preferred are IL-18 antagonists
including IL-18 antibodies or soluble IL-18 receptors, or IL-18
binding proteins. It has been shown that TNF.alpha. and IL-18 have
overlapping but distinct functions and a combination of antagonists
to both may be most effective. Yet another preferred combination
are non-depleting anti-CD4 inhibitors. Yet other preferred
combinations include antagonists of the co-stimulatory pathway CD80
(B7.1) or CD86 (B7.2) including antibodies, soluble receptors or
antagonistic ligands.
[0178] The TNF.alpha. inhibitors, including antibodies, or antigen
binding portions thereof, used in the invention may also be
combined with agents, such as methotrexate, 6-MP, azathioprine
sulphasalazine, mesalazine, olsalazine
chloroquinine/hydroxychloroquine, pencillamine, aurothiomalate
(intramuscular and oral), azathioprine, cochicine, corticosteroids
(oral, inhaled and local injection), beta-2 adrenoreceptor agonists
(salbutamol, terbutaline, salmeteral), xanthines (theophylline,
aminophylline), cromoglycate, nedocromil, ketotifen, ipratropium
and oxitropium, cyclosporin, FK506, rapamycin, mycophenolate
mofetil, leflunomide, NSAIDs, for example, ibuprofen,
corticosteroids such as prednisolone, phosphodiesterase inhibitors,
adensosine agonists, antithrombotic agents, complement inhibitors,
adrenergic agents, agents which interfere with signaling by
proinflammatory cytokines such as TNF.alpha. or IL-1 (e.g. IRAK,
NIK, IKK, p38 or MAP kinase inhibitors), IL-1.beta. converting
enzyme inhibitors, TNF.alpha. converting enzyme (TACE) inhibitors,
T-cell signalling inhibitors such as kinase inhibitors,
metalloproteinase inhibitors, sulfasalazine, azathioprine,
6-mercaptopurines, angiotensin converting enzyme inhibitors,
soluble cytokine receptors and derivatives thereof (e.g. soluble
p55 or p75 TNF receptors and the derivatives p75TNFRIgG (Enbrel.TM.
and p55TNFRIgG (Lenercept)), sIL-1 RI, sIL-IRII, sIL-6R),
antiinflammatory cytokines (e.g. IL-4, IL-10, IL-11, IL-13 and
TGF.beta.), tocilizumab (Actemra), celecoxib, folic acid,
hydroxychloroquine sulfate, rofecoxib, etanercept, infliximab,
naproxen, valdecoxib, sulfasalazine, methylprednisolone, meloxicam,
methylprednisolone acetate, gold sodium thiomalate, aspirin,
triamcinolone acetonide, propoxyphene napsylate/apap, folate,
nabumetone, diclofenac, piroxicam, etodolac, diclofenac sodium,
oxaprozin, oxycodone hcl, hydrocodone bitartrate/apap, diclofenac
sodium/misoprostol, fentanyl, anakinra, human recombinant, tramadol
hcl, salsalate, sulindac, cyanocobalamin/fa/pyridoxine,
acetaminophen, alendronate sodium, prednisolone, morphine sulfate,
lidocaine hydrochloride, indomethacin, glucosamine
sulf/chondroitin, amitriptyline hcl, sulfadiazine, oxycodone
hcl/acetaminophen, olopatadine hcl, misoprostol, naproxen sodium,
omeprazole, cyclophosphamide, rituximab, IL-1 TRAP, MRA, CTLA4-IG,
IL-18 BP, anti-IL-18, Anti-IL15, BIRB-796, SCIO-469, VX-702,
AMG-548, VX-740, Roflumilast, IC-485, CDC-801, and Mesopram.
Preferred combinations include methotrexate or leflunomide and in
moderate or severe AS cases, cyclosporine.
[0179] Non-limiting examples of therapeutic agents for AS with
which TNF.alpha. inhibitor, such as an antibody, or antibody
portion, can be combined include the following: methotrexate,
etanercept, rofecoxib, celecoxib, folic acid, sulfasalazine,
naproxen, leflunomide, methylprednisolone acetate, indomethacin,
hydroxychloroquine sulfate, prednisone, sulindac, betamethasone
diprop augmented, infliximab, methotrexate, folate, triamcinolone
acetonide, diclofenac, dimethylsulfoxide, piroxicam, diclofenac
sodium, ketoprofen, meloxicam, methylprednisolone, nabumetone,
tolmetin sodium, calcipotriene, cyclosporine, diclofenac
sodium/misoprostol, fluocinonide, glucosamine sulfate, gold sodium
thiomalate, hydrocodone bitartrate/apap, ibuprofen, risedronate
sodium, sulfadiazine, thioguanine, valdecoxib, alefacept,
efalizumab.
[0180] Non-limiting examples of therapeutic agents for Ankylosing
Spondylitis with which an antibody, or antibody portion, of the
invention can be combined include the following: ibuprofen,
diclofenac and misoprostol, naproxen, meloxicam, indomethacin,
diclofenac, celecoxib, rofecoxib, Sulfasalazine, Methotrexate,
azathioprine, minocyclin, prednisone, etanercept, infliximab. In
one embodiment, the methods of the invention include the
combination of a TNF.alpha. inhibitor and methotrexate.
IV. Efficacy of TNF.alpha. Inhibitor
[0181] The invention also provides methods for determining whether
a TNF.alpha. inhibitor is effective at treating AS in a subject.
Such methods may be used to determine the efficacy of a TNF.alpha.
inhibitor, including those which are unknown or unconfirmed to have
such efficacy. Using the methods described herein, effective
TNF.alpha. inhibitors may be determined or confirmed, and,
subsequently, used in the method of treating AS.
[0182] Methods of determining efficacy of a TNF.alpha. inhibitor
for treating ankylosing spondylitis (AS) in a subject include any
means known in the art. The clinical course of AS is measured by
using any number of instruments to evaluate various AS symptoms.
Some of the commonly used scales include the Assessment in
Ankylosing Spondylitis (ASAS), the Bath Ankylosing Spondylitis
Disease Activity Index (BASDAI) (Garrett et al. (1994) J Rheumatol
21:2286), the Bath Ankylosing Spondylitis Metrology Index (BASMI)
(Jenkinson et al. (1994) J Rheumatol 21:1694), and the Bath
Ankylosing Spondylitis Functional Index (BASFI) (Calin et al.
(1994) J Rheumatol 21:2281). These indices can be used to monitor a
patient over time and to determine improvement. Each of these
scales is described further below, as well as in the examples:
Criteria for Measuring the Clinical Course of AS
[0183] 1. The Assessment in Ankylosing Spondylitis (ASAS20) is the
primary endpoint in the pivotal Phase 3 AS studies. A .gtoreq.20%
improvement and absolute improvement of .gtoreq.210 units (scale of
0-100) in .gtoreq.3 of 4 domains: Subject Global Assessment, Pain,
Function, and Inflammation. There must be an absence of
deterioration in the potential remaining domain (deterioration is
defined as a change for the worse of .gtoreq.20% and a net
worsening of .gtoreq.10 units (scale of 0-100). 2. The Bath
Ankylosing Spondylitis Disease Activity Index (BASDAI) can be used
to evaluate the level of disease activity in a patient with AS.
BASDAI focuses upon signs and symptoms of the inflammatory aspects
of AS, nocturnal and total back pain, the patient's global
assessment and actual physical measurements of spinal mobility such
as the Schober's test, chest expansion score and occiput to wall
measurement. BASDAI measures disease activity on the basis of six
questions relating to fatigue, spinal pain, peripheral arthritis,
enthesitis (inflammation at the points where
tendons/ligaments/joint capsule enter the bone), and morning
stiffness. These questions are answered on a 10-cm horizontal
visual analog scale measuring severity of fatigue, spinal and
peripheral joint pain, localized tenderness, and morning stiffness
(both qualitative and quantitative). The final BASDAI score has a
range of 0 to 10. 3. The Bath Ankylosing Spondylitis Functional
Index (BASFI) measures the physical function impairment caused by
AS, and is a self-assessment instrument that consists of 8 specific
questions regarding function in AS, and 2 questions reflecting the
patient's ability to cope with everyday life. Each question is
answered on a 10-cm horizontal visual analog scale, the mean of
which gives the BASFI score (0-10). 4. The Bath Ankylosing
Spondylitis Metrology Index (BASMI) consists of 5 simple clinical
measurements that provide a composite index and define disease
status in AS. Analysis of metrology (20 measurements) identified
these 5 measurements as most accurately reflecting axial status:
cervical rotation, tragus to wall distance, lateral flexion,
modified Schober's test, and internalleolar distance. The BASMI is
quick (7 minutes), reproducible, and sensitive to change across the
entire spectrum of disease. The BASMI index comprises 5 measures of
hip and spinal mobility in AS. The five BASMI measures, scaled 0
(mild) to 10 (severe), include tragus to wall distance, cervical
rotation, lumbar flexion, lumbar side flexion, and intermolleolar
distance.
[0184] Combinations of the above-mentioned criteria may also used
to evaluate patients. In addition, other indices such as FACIT-F or
the ability of the TNF.alpha. inhibitor to induce partial remission
can be used to determine disease activity in AS patients.
[0185] The invention provides methods for determining whether a
TNF.alpha. inhibitor is effective at treating AS in a subject. Such
methods may be used to determine the efficacy of a TNF.alpha.
inhibitor, including those which are unknown or unconfirmed to have
such efficacy. Using the methods described herein, effective
TNF.alpha. inhibitors may be determined or confirmed, and,
subsequently, used in the method of treating AS.
[0186] In one embodiment, the invention provides a method for
determining efficacy using a Bath Ankylosing Spondylitis Disease
Activity Index (BASDAI) 20 response. The invention includes a
method of determining the efficacy of a TNF.alpha. inhibitor for
treating ankylosing spondylitis (AS) in a subject comprising
determining a Bath Ankylosing Spondylitis Disease Activity Index
(BASDAI) 20 response of a patient population having AS and who was
administered the TNF.alpha. inhibitor, wherein an BASDAI 20
response in at least about 60% of the patient population indicates
that the TNF.alpha. inhibitor is an effective TNF.alpha. inhibitor
for the treatment of AS in a subject.
[0187] The invention further provides a method of treating AS in a
subject comprising administering an effective TNF.alpha. inhibitor
to the subject such that AS is treated, wherein the effective
TNF.alpha. inhibitor was previously identified as resulting in a
BASDAI 20 response in at least about 60% of a patient population
having AS and who was administered the TNF.alpha. inhibitor. In one
embodiment, the effective TNF.alpha. inhibitor was previously
identified as resulting in a BASDAI 20 response in at least about
65% of a patient population having AS and who was administered the
TNF.alpha. inhibitor. In one embodiment, the effective TNF.alpha.
inhibitor was previously identified as resulting in a BASDAI 20
response in at least about 70% of a patient population having AS
and who was administered the TNF.alpha. inhibitor. In one
embodiment, the effective TNF.alpha. inhibitor was previously
identified as resulting in a BASDAI 20 response in at least about
75% of a patient population having AS and who was administered the
TNF.alpha. inhibitor. In one embodiment, the effective TNF.alpha.
inhibitor was previously identified as resulting in a BASDAI 20
response in at least about 80% of a patient population having AS
and who was administered the TNF.alpha. inhibitor. In one
embodiment, the effective TNF.alpha. inhibitor was previously
identified as resulting in a BASDAI 20 response in at least about
85% of a patient population having AS and who was administered the
TNF.alpha. inhibitor. In one embodiment, an BASDAI 20 response in
at least about 60%, 61%, 62%, 63%, 64%, 65%, 66%, 67%, 68%, 69%,
70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%, 78%, 79%, 80%, 81%, 82%,
83%, 84%, 85%, of the patient population indicates that the
TNF.alpha. inhibitor is an effective TNF inhibitor for the
treatment of AS in the subject.
[0188] The invention also includes a method of determining the
efficacy of a TNF.alpha. inhibitor for treating ankylosing
spondylitis (AS) in a subject comprising determining a Bath
Ankylosing Spondylitis Disease Activity Index (BASDAI) 50 response
of a patient population having AS and who was administered the
TNF.alpha. inhibitor, wherein an BASDAI 50 response in at least
about 65% of the patient population indicates that the TNF.alpha.
inhibitor is an effective TNF.alpha. inhibitor for the treatment of
AS in the subject. In one embodiment, an BASDAI 50 response in at
least about 23%, at least about 30%, at least about 35%, at least
about 40%, at least about 45%, at least about 50%, at least about
55%, or at least about 60%, of the patient population indicates
that the TNF.alpha. inhibitor is an effective TNF inhibitor for the
treatment of AS in the subject. In one embodiment, an BASDAI 50
response in at least about 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%,
31%, 32%, 33%, 34%. 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%,
44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%,
57%, 58%, 59%, 60% of the patient population indicates that the
TNF.alpha. inhibitor is an effective TNF inhibitor for the
treatment of AS in the subject.
[0189] The invention further provides a method of determining the
efficacy of a TNF.alpha. inhibitor for treating ankylosing
spondylitis (AS) in a subject comprising determining a Bath
Ankylosing Spondylitis Disease Activity Index (BASDAI) 70 response
of a patient population having AS and who was administered the
TNF.alpha. inhibitor, wherein an BASDAI 70 response in at least
about 10% of the patient population indicates that the TNF.alpha.
inhibitor is an effective TNF.alpha. inhibitor for the treatment of
AS in the subject. In one embodiment, an BASDAI 50 response in at
least about 15%, at least about 20%, at least about 25%, at least
about 30%, at least about 35%, at least about 40%, at least about
45%, of the patient population indicates that the TNF.alpha.
inhibitor is an effective TNF inhibitor for the treatment of AS in
the subject. In one embodiment, an BASDAI 50 response in at least
about 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%.
35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, of the
patient population indicates that the TNF.alpha. inhibitor is an
effective TNF inhibitor for the treatment of AS in the subject.
[0190] The invention provides a method of treating AS in a subject
comprising administering an effective TNF.alpha. inhibitor to the
subject such that AS is treated, wherein the effective TNF.alpha.
inhibitor was previously identified as resulting in an ASAS20
response in at least about 61% of a patient population having AS
who was administered the TNF.alpha. inhibitor. In one embodiment,
an ASAS20 response in at least about 27%, at least about 30%, at
least about 35%, at least about 40%, at least about 45%, at least
about 50%, at least about 55%, at least about 60%, at least about
65%, or at least about 70% of the patient population indicates that
the TNF.alpha. inhibitor is an effective TNF.alpha. inhibitor for
the treatment of AS in the subject. In one embodiment, an ASAS20
response in at least about 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%.
35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%,
48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%,
61%, 62%, 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, or 73%
of the patient population indicates that the TNF.alpha. inhibitor
is an effective TNF.alpha. inhibitor for the treatment of AS in the
subject
[0191] The invention also includes a method of determining the
efficacy of a TNF.alpha. inhibitor for treating ankylosing
spondylitis (AS) in a subject comprising determining a Assessment
in Apkylosing Spondylitis (ASAS) response of a patient population
having AS and who was administered the TNF.alpha. inhibitor,
wherein an ASAS40 response in at least about 39% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS in the subject. In one
embodiment, an ASAS40 response in at least about 40% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS in the subject. In one
embodiment, an ASAS40 response in at least about 41% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS in the subject.
[0192] The invention also includes a method of determining the
efficacy of a TNF.alpha. inhibitor for treating ankylosing
spondylitis (AS) in a subject comprising determining a Assessment
in Ankylosing Spondylitis (ASAS) response of a patient population
having AS and who was administered the TNF.alpha. inhibitor,
wherein an ASAS50 response in at least about 39% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS in the subject. In one
embodiment, an ASAS50 response in at least about 40% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS in the subject.
[0193] The invention also includes a method of determining the
efficacy of a human TNF.alpha. antibody or for treating ankylosing
spondylitis (AS) in a subject comprising determining a Assessment
in Ankylosing Spondylitis (ASAS) 70 response of a patient
population having AS and who was administered the human TNF.alpha.
antibody, or antigen-binding portion thereof, wherein an ASAS70
response in at least about 5% of the patient population indicates
that the human TNF.alpha. antibody, or antigen-binding portion
thereof, is an effective human TNF.alpha. antibody, or
antigen-binding portion thereof, for the treatment of AS in the
subject. In one embodiment, an ASAS70 response in at least about
20% of the patient population indicates that the human TNF.alpha.
antibody, or antigen-binding portion thereof, is an effective human
TNF.alpha. antibody, or antigen-binding portion thereof, for the
treatment of AS in the subject. In one embodiment, an ASAS70
response in at least about 25% of the patient population indicates
that the human TNF.alpha. antibody, or antigen-binding portion
thereof, is an effective human TNF.alpha. antibody, or
antigen-binding portion thereof, for the treatment of AS in the
subject. In one embodiment, an ASAS70 response in at least about
30% of the patient population indicates that the human TNF.alpha.
antibody, or antigen-binding portion thereof, is an effective human
TNF.alpha. antibody, or antigen-binding portion thereof, for the
treatment of AS in the subject. In one embodiment, an ASAS70
response in at least about 40% of the patient population indicates
that the human TNF.alpha. antibody, or antigen-binding portion
thereof, is an effective human TNF.alpha. antibody, or
antigen-binding portion thereof, for the treatment of AS in the
subject. In one embodiment, an ASAS70 response in at least about
5%, at least about 20%, at least about 24%, or at least about 40%
of the patient population indicates that the TNF.alpha. inhibitor
is an effective TNF.alpha. inhibitor for the treatment of AS in the
subject. In one embodiment, an ASAS70 response in at least about
5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%,
19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%,
32%, 33%, 34%. 35%, 36%, 37%, 38%, 39%, or 40% of the patient
population indicates that the TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor for the treatment of AS in the subject.
[0194] Numbers intermediate to any percentages recited herein,
including those in the Examples, e.g., 61%, 62%, 63%. 64%, 65%,
66%, 67%, 68%, 69%, are also intended to be part of this invention.
Ranges of values using a combination of any of the above recited
values as upper and/or lower limits are intended to be included in
the scope of the invention
[0195] The invention may also include further comprising
administering the effective human TNF.alpha. antibody, or
antigen-binding portion thereof, described herein to a subject to
treat AS.
[0196] Also encompassed in the invention is a method of treatment
comprising administering a TNF.alpha. inhibitor shown to be
efficacious according to the methods described herein and in the
Examples. In one embodiment, the methods of the invention comprise
administering the TNF.alpha. inhibitor to the subjects of a patient
population and determining the efficacy of the TNF.alpha. inhibitor
by determining changes, improvements, measurements, etc., using AS
indices known in the art, in the patient population in comparison
to the Examples set forth below. For example, the invention further
provides a method of treating AS in a subject comprising
administering an effective TNF.alpha. inhibitor to the subject such
that AS is treated, wherein the effective TNF.alpha. inhibitor was
previously identified as resulting in a BASDAI 50 response in at
least about 60% of a patient population having AS and who was
administered the TNF.alpha. inhibitor.
[0197] It should be noted that the Examples provided herein
represent different methods of determining the efficacy of a
TNF.alpha. inhibitor, such as a human TNF.alpha. antibody, or
antigen-binding portion thereof. As such, data and results
described in the Examples section which shows efficacy of a
TNF.alpha. inhibitor, e.g., ability to treat AS, are included in
the methods of determining efficacy of the invention.
[0198] Time points for determining efficacy will be understood by
those of skill in the art to depend on the type of efficacy being
determined, e.g., induction of partial remission. In one
embodiment, measurements in scores, e.g., an improvement in the
ASAS20 response, may be measured against a subject's baseline
score. Generally, a baseline refers to a measurement or score of a
patient before treatment, i.e. week 0. Other time points may also
be included as a starting point in determining efficacy,
however.
[0199] Patient populations described in the methods of the
invention are generally selected based on common characteristics,
such as, but not limited to, subjects diagnosed with AS. Such a
patient population would be appropriate, for example, for
determining the efficacy of the TNF.alpha. inhibitor for inducing
partial remission in AS in the given patient population. In one
embodiment, the patient population is an adult population.
[0200] In one embodiment, the methods of the invention for
determining whether a TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor, include determining changes, improvements,
measurements, etc., in AS using appropriate indices described
herein, e.g., ASAS responses, BASDAI, from a patient population who
has already been administered the TNF.alpha. inhibitor. Such a
patient population may be pre-selected according to common
characteristics, e.g., AS, and may have already been given the
TNF.alpha. inhibitor. Administration of the TNF.alpha. inhibitor
may or may not be performed by the same person of ordinary skill
who is determining the efficacy of the TNF.alpha. inhibitor in
accordance with the teachings of the specification.
[0201] Methods of the invention relating to determining efficacy,
i.e., determining whether a TNF.alpha. inhibitor is an effective
TNF.alpha. inhibitor, may also be applied to specific patient
populations within the overall patient population who together have
specific, common characteristics, i.e., a subpopulation. In
addition, while the above methods are described in terms of patient
populations, methods of efficacy described herein may also be
applied to individual subjects.
[0202] The Examples and discoveries described herein are
representative of a TNF.alpha. inhibitor, i.e., adalimumab, which
is effective for treating AS, including reducing pain and fatigue
and inducing partial remission of AS. As such, the studies and
results described in the Examples section herein may be used as a
guideline for determining the efficacy of a TNF.alpha. inhibitor,
i.e., whether a TNF.alpha. inhibitor is an effective TNF.alpha.
inhibitor for the treatment of AS. In one embodiment, methods of
determining efficacy described herein may be used to determine
whether a TNF.alpha. inhibitor is bioequivalent to another
TNF.alpha. inhibitor.
The present invention is further illustrated by the following
examples which should not be construed as limiting in any way.
EXAMPLES
Example 1
Adalimumab in the Treatment of Active Ankylosing Spondylitis:
Results of an Open-Label, 52-Week Trial
[0203] Tumor necrosis factor (TNF) antagonists infliximab and
etanercept have shown efficacy in the treatment of ankylosing
spondylitis (AS). Adalimumab (Abbott Laboratories) is a fully
human, anti-TNF monoclonal antibody that reduces the signs and
symptoms and progression of disease of rheumatoid arthritis and has
been evaluated in AS over 20 weeks.
[0204] The objective of this study was to examine the potential
therapeutic effects of adalimumab in NSAID-refractory AS patients
who were treated for 52 weeks (Ann Rheum Dis 2005; 64(Suppl
III):316). To further this objective, fifteen patients were
enrolled (patient characteristics are detailed in Table 1). All
patients suffered from spinal pain, and 4 patients also had
peripheral arthritis. Adalimumab 40 mg was administered
subcutaneously every other week (eow). Clinical outcome assessments
included disease activity (BASDAI), function (BASFI), metrology
(BASMI), patient's and physician's global and nocturnal assessments
of pain (NRS), peripheral joint assessment, Maastricht enthesitis
score, quality of life (SF-36), and C-reactive protein (CRP). The
primary endpoint of this study was improvement of disease activity
(BASDAI 50%) at Week 12. Outcome parameters are listed in Table
2.
TABLE-US-00001 TABLE 1 Patient Characteristics. Number of patients
(n) 15 Male/female (n) 9/6 Mean age, years (range) 40 (19-55) Mean
disease duration, years (range) 11 (2-33) HLA-B27 positive 86% Mean
BASDAI (range) 6.6 (4.7-8.5) Patients with joint involvement (n)
4
TABLE-US-00002 TABLE 2 Outcome Parameters. Baseline Week 2 Week 12
Week 52 BASFI 6.3 5.1 4.3 3.7 BASMI 4.5 3.8 3.9 3.4 General Pain
7.4 5.1 4.1 3.4 Nocturnal Pain 7.3 4.7 4.0 3.2 Patient's global 7.3
5.0 4.3 3.1
[0205] Thirteen patients completed the 52-week therapy. One patient
withdrew after 8 weeks for personal reasons; and the other patient
withdrew because of inefficacy and remitting minor infections at
Week 28.
[0206] At Week 52, the BASDAI showed a significant improvement (see
FIG. 1). For example, at 52 weeks, over 75% of patients treated
with adalimumab had achieved a BASDAI20 response, about 60% had
achieved a BASDAI50 response, and more than 45% had achieved a
BASDAI70 response.
[0207] Similar levels of improvement were achieved in applying the
Assessment of Ankylosing Spondylitis (ASAS) working group
improvement criteria (see FIG. 2). At 52 weeks, about 73% of
patients treated with adalimumab had achieved an ASAS20 response,
about 70% achieved an ASAS40 response, and about 40% achieved an
ASAS70 response.
[0208] In addition, the CRP, BASFI, patient's and physician's
global assessments, general and nocturnal assessments of pain
(NRS), BASMI, morning stiffness (BASDAI Question 4 and 5) and the
Physical Component Summary (PCS) of SF-36 improved significantly.
Adalimumab was well-tolerated, and no serious infections occurred
during the study. In this open-label study, adalimumab showed
significant and sustained improvement of spinal symptoms in active
AS over 1 year.
Example 2
Adalimumab Reduces Fatigue in Patients with Active Ankylosing
Spondylitis (AS)
[0209] Fatigue, defined as enduring, subjective sensation of
generalized tiredness or exhaustion, has been increasingly
recognized as an important outcome measure in AS (Dagfinrud et al.
Arth Rheum 2005; 53(1):5-11; Jones S D et al. J Rheumatol 1996;
23(3):487-90; Haywood H L et al. Rheumatol 2002; 41:1295-1302; Ward
M M. Arth Care Res 1999; 12:247-55; Van Tubergen et al. Arth Rheum
2002; 27(1):8-16). It has been reported that 65% of people living
with AS describe fatigue as a major symptom from time to time
(Jones S D et al. J Rheumatol 1996; 23(3):487-90). The objective of
this study was to evaluate the impact of adalimumab therapy (a TNF
antagonist) on fatigue in active AS patients.
Overview
[0210] This phase III, double-blind, randomized, placebo-controlled
trial was conducted at 11 sites in Canada (study design is shown in
FIG. 3). The study enrolled active AS patients with an inadequate
response to at least one NSAID. The study included a 24-week study
period of 40 mg adalimumab subcutaneous (sc) injection every other
week (eow) or placebo.
[0211] There was an early escape option to open label 40 mg
adalimumab sc eow at Weeks 12, 16, or 20. Patients completed a
questionnaire on disease activity (BASDAI [Bath Ankylosing
Spondylitis Disease Activity Index]). Fatigue was assessed by
patient self-reported questionnaires, including FACIT-Fatigue,
BASDAI Fatigue item, and SF-36 Vitality domain.
Instruments for Fatigue Assessments
[0212] FACIT-Fatigue is a widely used measure of fatigue in chronic
illnesses. This measure contains 13 items pertaining to the past 7
days to be rated on a 5-point Likert scale. Scores range from 0-52,
with higher scores representing less fatigue. A 3-point or more
change is considered clinically meaningful (Cella et al. Cancer
2002; 94:528-538; and Cella et al. J Clin Oncol 2003; 21:366).
FACIT-Fatigue was administered at Baseline and at Weeks 2, 12, and
24.
[0213] The BASDAI scale is widely used in clinical studies to
evaluate AS disease activity. The BASDAI is a six-item measure of
disease activity and includes questions on fatigue, spinal pain,
peripheral arthritis, enthesitis, and duration and severity of
morning stiffness. The BASDAI scale has six items pertaining to the
past 7 days on a 10-cm visual analog scale (VAS). Fatigue is the
first item on the BASDAI scale, asking the subject to rate "overall
degree of tiredness" during the past 7 days on a 10-cm VAS. BASDAI
Fatigue Item scores range from 0-10, with lower scores representing
less fatigue. BASDAI was administered at Baseline and at Weeks 2,
4, 8, 12, 16, 20, and 24
[0214] SF-36 is a widely applied instrument for measuring health
status, and consists of 8 domains: physical function, bodily pain,
role limitations-physical, general health, vitality, social
function, role limitations-emotional, and mental health. The
Vitality domain has four items to measure energy level and fatigue.
SF-36 has a 4-week recall period, and domain scores range from
0-100, with higher scores reflecting better health status. A 5-10
point change in domain scores is considered clinically meaningful
(Kosinski M et al. Arth Rheum 2000; 7:1478-1487). SF-36 also
contains 2 summary scores, the mental component summary (MCS) and
the physical component summary (PCS); a 2.5-5 point change in
summary scores is considered clinically meaningful (Kosinski M et
al. Arth Rheum 2000; 7:1478-1487). SF-36 was administered at
Baseline and at Weeks 12 and 24.
[0215] Patient disposition at Week 24 is shown in Table 3. Baseline
demographics and disease activity are shown in Table 4.
Patient-Reported Fatigue and Health-Related Quality of Life (HRQL)
Scores at Baseline are shown in Table 5.
TABLE-US-00003 TABLE 3 Patient Disposition at Week 24 Adalimumab
Placebo 40 mg eow (N = 44) (N = 38) n (%) n (%) Subjects Randomized
44 38 Subjects Treated 44 38 Subjects Completing Week 24 44 (100)
38 (100) Prematurely terminated at 2 (4.5) 0 Week 24 AE 0 0
Withdrew consent 1 (2.3) 0 Lost to follow-up 0 0 Other 1 (2.3)
0
TABLE-US-00004 TABLE 4 Baseline Demographics and Disease Activity
Adalimumab Placebo 40 mg eow (N = 107) (N = 208) n (%) n (%)
p-value Age (years) 43.4 41.7 0.220a Sex (males) 79 (73.8) 157
(75.5) 0.784b Race (Whites) 99 (92.5) 202 (97.1) 0.050, b Weight
(kg) 79.8 81.9 0.320 HLA-B27 positive 85 (79.4) 163 (78.4) 0.960b
Duration of AS 10.0 11.3 0.261a (years) BASDAI score 6.3 6.3
0.633a
TABLE-US-00005 TABLE 5 Patient-Reported Fatigue and Health-Related
Quality of Life (HRQL) Score at Baseline* Placebo Adalimumab 40 mg
(N = 44) eow (N = 38) p-value FACIT-Fatigue 23.6 (+9.9) 24.4
(+10.8) 0.770 BASDAI Fatigue 6.9 (+1.9) 6.3 (+2.3) 0.357 Item SF-36
Vitality 34.6 (+18.4) 30.4 (+17.9) 0.325 Domain SF-36 PCS 32.8
(+7.3) 32.9 (+8.3) 0.868 SF-36 MCS 41.6 (+10.0) 42.8 (+9.5) 0.517
*Mean + standard deviation
[0216] Data from the study is shown below. Patients with active AS
experienced fatigue symptom and impairment in physical functioning
at Baseline. Compared with placebo, adalimumab treatment
demonstrated statistically significant improvement in disease
activity (as measured by BASDAI, see Table 6)).
TABLE-US-00006 TABLE 6 Change from Baseline to Weeks 12 and 24 in
Disease Activity-BASDAI Score Mean change in BASDAI score* Placebo
Adalimumab Week 12 -0.51 -2.04** Week 24 -0.37 -1.99** *Mean change
from baseline (LOCF). **Statistically significant at p .ltoreq.
0.01 level, p-value for difference between therapies from
ANCOVA.
[0217] After 12 and 24 weeks of adalimumab therapy, patients
reported statistically significant and clinically meaningful
improvements in fatigue symptom and functioning compared with
placebo (FACIT-Fatigue scores for the two treatment groups are
shown in Table 7 and FIG. 4).
TABLE-US-00007 TABLE 7 Change from Baseline to Weeks 12 and 24 in
FACIT-Fatigue Score Mean change in FACIT-Fatigue score.sup..dagger.
Placebo Adalimumab Week 12 1.7 7.0** Week 24 2.5 7.8*
.sup..dagger.Mean change from baseline (LOCF). *, **Statistically
significant at p .ltoreq. 0.05 and p .ltoreq. 0.01 levels,
respectively. Minimum Important Difference = 3 Cella et al. Cancer
2002; 94: 528-538 Cella et al. J Clin Oncol 2003; 21: 366-373.
[0218] A statistically significant difference in BASDAI Fatigue
Item Score was seen between the placebo and adalimumab treatment
groups at Weeks 12 and 24, as shown in Table 8 and FIG. 5.
TABLE-US-00008 TABLE 8 Change from Baseline to Weeks 12 and 24 in
BASDAI Fatigue Item Score Mean change in BASDAI-Fatigue
score.sup..dagger. Placebo Adalimumab Week 12 -0.5 -1.7** Week 24
-0.5 -1.9** .sup..dagger.Mean change from baseline (LOCF).
**Statistically significant at p .ltoreq. 0.01 level.
[0219] Statistically significant improvements were also seen in the
adalimumab treatment group compared with placebo in the SF-36
Vitality Domain Score (Table 9 and FIG. 6), the SF-36 PCS Score
(Table 10), and the SF-36 MCS Score (Table 11).
TABLE-US-00009 TABLE 9 Change from Baseline to Weeks 12 and 24 in
SF-36 Vitality Domain Score Mean change in SF-36 Vitality Domain
Score.sup..dagger. Placebo Adalimumab Week 12 1.3 17 Week 24 2.8
18.1 .sup..dagger.Mean change from baseline (LOCF). Minimum
Important Difference = 10 Kosinski M et al. Arth Rheum 2000; 7:
1478-1487.
TABLE-US-00010 TABLE 10 Change from Baseline in Weeks 12 and 24 in
SF-36 PCS Score Mean change in SF-36 PCS Score.sup..dagger. Placebo
Adalimumab Week 12 0.9 7.8*** Week 24 1.1 6.1*** .sup..dagger.Mean
change from baseline (LOCF). ***Statistically significant at p
.ltoreq. 0.001 level. Minimum Important Difference = 3 Kosinski M
et al. Arth Rheum 2000; 7: 1478-1487.
TABLE-US-00011 TABLE 11 Change from Baseline in Weeks 12 and 24 in
SF-36 MCS Score SF-36 MCS Score.sup..dagger. Placebo Adalimumab
Week 12 0.0 5.4 Week 24 1.1 6.1 .sup..dagger.Mean change from
baseline (LOCF). Minimum Important Difference = 3 Kosinski M et al.
Arth Rheum 2000; 7: 1478-1487.
[0220] In conclusion, these results show that adalimumab treatment
may reduce fatigue and improve functioning in AS patients.
Example 3
Major Clinical Response and Partial Remission in Ankylosing
Spondylitis Subjects Treated with Adalimumab: Study H
[0221] Ankylosing Spondylitis (AS) is a common inflammatory
rheumatic disease that produces progressive spinal stiffness and
restriction of mobility. Tumor necrosis factor (TNF) is thought to
play a major role in the pathogenesis of AS. No trial of a
disease-modifying antirheumatic drug (DMARD) has yielded consistent
positive results for the treatment of AS.
[0222] Adalimumab is a fully human monoclonal antibody targeting
TNF, currently approved for the treatment of rheumatoid arthritis
and psoriatic arthritis in the US and Europe, and currently pending
approval from the FDA and EMEA for AS. The objective of the study
described herein was to investigate the ability of adalimumab to
effect a major clinical response and partial remission in subjects
with ankylosing spondylitis. Partial remission is defined as a
value of <20 on a 0-100 VAS scale in each of the 4 ASAS domains:
Pain (Total Back Pain [TBP]), Function (Bath AS Functional Index
[BASFI], Patient's Global Assessment (PGA) of disease activity, and
Inflammation (Bath AS Disease Activity Index [BASDAI] questions 5
and 6).
[0223] Study H was a phase III, randomized, placebo-controlled,
double-blind, multi-center study designed to assess the efficacy
and safety of adalimumab in the treatment of active AS in subjects
who had an inadequate response, or were intolerant to, treatment
with at least one nonsteroidal anti-inflammatory drug (NSAID).
Patients may have also had inadequate response to at least one
DMARD. Thus, the study included subjects who had failed previous
conventional therapy for AS.
[0224] Study H was a 2-year study in which subjects were randomized
in a 2:1 ratio to receive either 40 mg subcutaneous (sc) doses of
adalimumab or placebo every other week (eow). After the initial
24-week blinded period, patients had the option to participate in a
subsequent 80-week open label extension. The study design of Study
H is outlined in FIG. 7. Subjects who failed to achieve an
Assessment in Ankylosing Spondylitis (ASAS) 20 response at or after
Week 12 were eligible for open-label early escape therapy (EET)
with adalimumab 40 mg sc eow. Subjects receiving early escape
therapy were treated as nonresponders at all subsequent visits. All
patients were assessed at Weeks 2, 4, 8, 12, 16, 20, and 24.
[0225] Patient inclusion criteria were inadequate response to at
least one NSAID, and active AS, defined by fulfillment of at least
2 of the following 3 criteria: Bath AS Disease Activity Index
(BASDAI) score .gtoreq.4, Visual Analog Scale (VAS) score for Total
Back Pain (TBP).gtoreq.4, and morning stiffness .gtoreq.1 hour.
Primary outcome measures were assessed at Weeks 12 and 24. Primary
outcome measures include ASAS Partial Remission Criteria (value of
<20 on a 0-100 scale in each of the 4 ASAS20 domains [Patient
Global Assessment, Total Back Pain, Bath AS Functional Index, Bath
AS Disease Activity Index questions 5 and 6]), and Major Clinical
Response. ASAS40 and ASAS 5/6 outcomes have both been considered as
candidate measures for determining Major Clinical Response. ASAS40
criteria represent a 40% improvement in 5 of 6 domains, without a
20% worsening in the sixth domain. ASAS 5/6 criteria represent a
20% improvement in 5 of 6 domains, without a 20% worsening in the
sixth domain. Domains include: pain (TBP), function (BASFI),
patient's Global Assessment (PGA) of disease activity, inflammation
(BASDAI questions 5 & 6), spinal mobility (Bath AS Metrology
Index [BASMI]), and C-reactive protein (CRP).
Results
[0226] A total of 315 subjects (adalimumab, n=208; placebo, n=107)
were enrolled. Baseline characteristics were similar between
subjects in each treatment arm. Baseline demographics are shown in
Table 12, and the disposition of subjects enrolled in the study is
shown in Table 13.
TABLE-US-00012 TABLE 12 Baseline Demographics Adalimumab Placebo 40
mg eow (N = 107) (N = 208) n (%) n (%) Mean Age (years) 43.4 41.7
Sex (males) 79 (73.8) 157 (75.5) Race (Whites) 99 (92.5) 202 (97.1)
Mean Weight (kg) 79.7 81.9 HLA-B27 (positive) 85 (79.4) 163 (78.4)
Mean Duration of AS (years) 10.0 11.3
TABLE-US-00013 TABLE 13 Disposition of Subjects Adalimumab Placebo
40 mg eow (%) N (%) Subjects Randomized 107 208 Subjects Treated
107 208 Subjects Completing Week 12 103 (96.3) 204 (98.1) Subjects
Completing Week 24 101 (94.4) 195 (93.8) Prematurely Terminated 4
(3.7) 4 (1.9) at Week 12 AE 2 (1.9) 2 (1.0) Withdrew Consent 0 2
(1.0) Lost to Follow Up 1 (0.9) 0 Other 2 (1.9) 2 (1.0) Prematurely
Terminated at 6 (5.6) 13 (6.3) Week 24 AE 2 (1.9) 5 (2.4) Withdrew
Consent 1 (0.9) 5 (2.4) Lost to Follow Up 1 (0.9) 2 (1.0) Other 4
(3.7) 4 (1.9)
[0227] The number of subjects who met the ASAS partial remission
criteria was significantly (p.ltoreq.0.001) higher for the
adalimumab group vs. placebo group at Week 12 (20.7% vs. 3.7%) and
at Week 24 (22.1% vs. 5.6%). Adalimumab vs. placebo subjects who
met the ASAS5/6 criteria were 48.6% vs. 13.1% (p.ltoreq.0.001) at
Week 12, and 44.7% vs. 12.1% (p.ltoreq.0.001) at Week 24,
respectively. The percentage of ASAS40 responders in adalimumab
patients was statistically significantly higher compared to placebo
responders at Week 12 (40.9% vs. 14.0%) and at Week 24 (39.4% vs.
14.0%), respectively (p.ltoreq.0.001, difference between therapies
from ANCOVA calculated using Pearson's Chi-square test). The onset
of improvement was rapid and sustained, as shown in FIG. 8 (ASAS40
response), as an improvement was seen within 2 weeks of
administration of adalimumab.
[0228] Adverse events (AE), serious AEs, and severe AEs were
comparable between both groups, as shown in Table 14. One serious
infectious AE was present in the placebo group. The adalimumab
group had no incidence of death, malignant neoplasm, or serious
infectious AE.
TABLE-US-00014 TABLE 14 Treatment-emergent Adverse Events (AEs)
Through Week 24.sup..dagger. Adalimumab Placebo 40 mg eow (N = 107)
(N = 208) Patients with: n (%) n (%) Any AE 66 (61.7) 163 (78.4)**
Serious AE 3 (2.8) 6 (2.9) Severe AE 4 (3.7) 6 (2.9) AE leading to
discontinuation 2 (1.9) 4 (1.9) of study drug AE at least possibly
drug- 18 (16.8) 74 (35.6)*** related Infectious AE 24 (22.4) 70
(33.7) Serious infectious AE 1 (0.9) 0 (0.0) Drug hypersensitivity
reaction 1 (0.9) 1 (0.4) .sup..dagger.During administration of
blinded study medication. **, ***Statistically significant at the p
= 0.01 and p = 0.001 levels, respectively.
Conclusions
[0229] Treatment with adalimumab was able to induce both a major
clinical response and partial remission over a 24-week period in
subjects with AS. Adalimumab was generally safe and well-tolerated.
Furthermore, response rates to adalimumab were rapid, as ASAS40
response rates improved within the first 2 weeks of treatment.
Example 4
Efficacy of Adalimumab in Active Ankylosing Spondylitis
(AS)--Results of the Canadian AS Study
[0230] Ankylosing spondylitis (AS) is a common inflammatory
rheumatic disease that produces progressive spinal stiffness and
restriction of mobility. Tumor necrosis factor (TNF) is thought to
play a major role in the pathogenesis of AS. No established
disease-modifying antirheumatic drug (DMARD) is presently available
for the treatment of AS. The purpose of the study described herein
was to evaluate the efficacy and safety of adalimumab vs. placebo
in patients with active AS.
[0231] A 2-year, randomized, placebo-controlled, double-blind,
Phase III trial was conducted at 11 sites in Canada. Patients with
active AS who had an inadequate response to at least one NSAID or
DMARD were eligible to enroll. The study design is outlined in FIG.
3. Patients were randomized to receive either placebo or adalimumab
40 mg subcutaneously (sc) every other week (eow) during an initial
24-week, double-blind period. Patient inclusion criteria were as
follows: patients were .gtoreq.18 years old, patients had
inadequate response to at least one NSAID, and patients had active
AS, defined by fulfillment of at least 2 of the following 3
criteria: BASDAI (Bath Ankylosing Spondylitis Disease Activity
Index) score .gtoreq.4, Visual Analog Scale (VAS) score for Total
Back Pain .gtoreq.4, morning stiffness .gtoreq.1 hour. Patient
exclusion criteria included the following: previously received
anti-TNF treatment, radiological evidence of total spinal ankylosis
(bamboo spine), use of previous DMARD within 4 weeks of Baseline
(other than methotrexate, sulfasalazine, or hydroxychloroquine),
intra-articular joint injection with corticosteroids within 4 weeks
of Baseline, and use of other biologics or investigational therapy
within 6 weeks of Baseline. Patients not achieving an ASAS20
(ASsessment in Ankylosing Spondylitis 20) response (calculated by
the site) after 12 weeks were eligible, per the protocol, for early
escape therapy (EET) of open-label 40 mg adalimumab eow. Any
patient receiving EET was treated as a nonresponder at all
subsequent visits in the statistical analysis.
[0232] Primary endpoints of the study were as follows: ASAS20 at
Week 12, ASAS International Working Group Criteria, pain (Total
Back Pain [TBP]), function (Bath AS Functional Index [BASFI]),
Patient's Global Assessment (PGA) of disease activity, and
inflammation (BASDAI questions 5 & 6). Secondary endpoints were
ASAS20 at Week 24, BASDAI 20/50/70 at 12 and 24 weeks, ASAS50 and
ASAS70 responses at 12 and 24 weeks, and PGA of disease activity at
12 and 24 weeks.
Results
[0233] A total of 82 patients (44 placebo, 38 adalimumab) were
enrolled. 80 (98%) patients completed the 24-week period. The 2
patients who did not complete the 24-week period were from the
placebo group. The 2 withdrawals from the 24 week period were not
related to adverse events. At Week 12, 28 patients randomized to
placebo and 20 patients randomized to adalimumab entered the EET
group (64% vs. 53%, respectively). At Week 20, 36 patients
randomized to placebo and 23 patients randomized to adalimumab
entered the EET group (82% vs. 61%, respectively). Baseline
characteristics were similar between treatment groups, as shown in
Table 15.
TABLE-US-00015 TABLE 15 Baseline Demographics Adalimumab Placebo 40
mg eow (N = 44) (N = 38) Mean age (years) 40.0 41.9 Race (%
Caucasian) 42 (95.5) 37 (97.4) Sex (% male) 36 (81.8) 29 (76.3)
Mean weight (kg) 78.2 76.1 Mean Duration of AS (years) 12.1
14.5
The number of DMARDs at Baseline was likewise similar among
treatment groups, as shown in Table 16.
TABLE-US-00016 TABLE 16 DMARDs at Baseline Adalimumab Placebo 40 mg
eow (N = 44) (N = 38) Baseline DMARD use.sup..dagger. 9 (20.5) 6
(15.8) Methotrexate.sup..dagger. 4 (9.1) 4 (10.5) Dose (mg/week)*
18.8 .+-. 894 2000 .+-. 0 Sulfasalazine.sup..dagger. 5 (11.4) 3
(7.9) Dose (mg/day)* 2400 .+-. 894 2000 .+-. 0
Leflunomide.sup..dagger. 0 0 Hydroxychloroquine.sup..dagger. 3
(6.8) 0
[0234] The ASAS20 response was higher in adalimumab (47%) vs.
placebo (27%) at Week 12. The number of patients achieving ASAS50
and ASAS70 responses at Week 12 was statistically significantly
higher for adalimumab patients compared to placebo patients (data
is shown in Table 17).
TABLE-US-00017 TABLE 17 ASAS20/50/70 Scores at Week 12.dagger. % of
Patients ASAS20 ASAS50 ASAS70 Placebo 27.3 6.8 2.3 Adalimumab 47.4
39.5*** 21.1* .dagger.Imputed. *, ***Statistically significant at p
= 0.05 and 0.001 levels, respectively.
[0235] Additionally, the ASAS20 response for adalimumab vs. placebo
was rapid and was statistically significant (p.ltoreq.0.01) at
Weeks 2, 4, 8, 16, and 20. Adalimumab patients showed significantly
greater improvement in TBP, BASFI, PGA and Inflammation scores at
Week 12 than did placebo patients (data is shown in Table 18).
TABLE-US-00018 TABLE 18 TBP, BASFI, PGA, and Inflammation Scores at
Week 12.dagger. % Change from Baseline TBP BASFI PGA Inflammation
Placebo -8.1 0.5 -5.0 -6.0 Adalimumab -40.5** -29.6** -36.1**
-39.1* .dagger.Imputed. *, ***Statistically significant at p = 0.05
and 0.01 levels, respectively.
[0236] At Week 12, EET was chosen by 64% of placebo and 53% of
adalimumab patients, and by 82% and 61% of patients, respectively,
at Week 20. The observed ASAS20 responses at Week 24 in patients
initially randomized to adalimumab and placebo were 60% and 73%,
respectively. Response to EET was rapid and sustained in the
placebo group. The ASAS20 response for those patients who switched
to EET at Week 12 is shown in FIG. 9. Five adalimumab patients with
an ASAS20 response at Week 8 had been assessed as nonresponders at
Week 12 and were switched to open-label therapy. Four of these 5
had regained an ASAS20 response at Week 16 and maintained it
through Week 24. The observed ASAS20 response time course is shown
in FIG. 10.
[0237] Both groups had comparable incidence of adverse events
(AEs), with none of these leading to discontinuation of the study
drug. Adalimumab patients had more infectious AEs (14 [37%] vs. 8
[18%] placebo patients; mostly upper respiratory infections). There
was no significant difference in serious adverse events (SAEs)
between groups and no deaths occurred. Treatment-emergent adverse
events (AEs) through Week 24 of the study are shown in Table 19,
and adverse events with .gtoreq.5% incidence through week 24 are
shown in Table 20.
TABLE-US-00019 TABLE 19 Treatment-Emergent Adverse Events (AEs)
Through Week 24 Adalimumab Placebo 40 mg eow (N = 44) (N = 38) n
(%) n (%) Any AE 30 (68.2) 33 (86.8) Serious AE 0 (0.0) 1 (2.6)
Severe AE 3 (6.8) 4 (10.5) AE leading to discontinuation 0 (0.0) 0
(0.0) of study drug AE at least possibly drug-related 13 (29.5) 12
(31.6) Infectious AE 8 (18.2) 14 (36.8) Serious infectious AE 0
(0.0) 1 (2.6)
TABLE-US-00020 TABLE 20 Adverse Events .gtoreq.5% Incidence Through
Week 24 Adalimumab Placebo 40 mg eow (N = 44) (N = 38) n (%) n (%)
Nasopharyngitis 5 (11.4) 7 (18.4) Headache 3 (6.8) 5 (13.2) Upper
respiratory tract infection 1 (2.3) 5 (13.2) Arthralgia 5 (11.4) 4
(10.5) Injection site reaction 4 (9.1) 3 (7.9) Dizziness 2 (4.5) 2
(5.3)
Conclusions
[0238] Adalimumab was efficacious in reducing the signs and
symptoms of active AS and was generally well-tolerated. The
possibility of early escape therapy influenced the results beyond
Week 8.
Example 5
Adalimumab Improves Health-Related Quality of Life in Patients with
Active Ankylosing Spondylitis--Study H
[0239] Ankylosing Spondylitis (AS) is a common inflammatory disease
that produces spinal stiffness and restriction of mobility. The
clinical symptoms and subsequent disease progression of AS may
result in functional limitations and impairment in HRQL. Tumor
necrosis factor (TNF) has been reported to play a major role in the
pathogenesis of AS. Adalimumab is a fully human monoclonal antibody
targeting TNF, currently approved for the treatment of rheumatoid
arthritis and psoriatic arthritis in the US and Europe. Adalimumab
is currently pending approval from the FDA and EMEA for AS. Study H
was a phase III, randomized, placebo-controlled, double-blind,
multi-center study designed to assess the efficacy and safety of
adalimumab in the treatment of active AS in subjects who had an
inadequate response, or were intolerant to, treatment with at least
one nonsteroidal anti-inflammatory drug (NSAID); patients may have
had an inadequate response to at least one DMARD (disease modifying
anti-rheumatic drug). The objective of the study described herein
was to assess the effect of adalimumab in improving function and
HRQOL in patients with active AS who were treated with adalimumab
in Study H.
[0240] Subjects were randomized to either adalimumab 40 mg every
other week or placebo for 24 weeks (study design for Study H is
outlined in FIG. 7). An early escape option to open label 40 mg
adalimumab sc eow was available at Week 12, or 16, or 20. Disease
activity was evaluated using the Bath Ankylosing Spondylitis
Disease Activity Index (BASDAI) patient-reported questionnaire.
Assessment in AS (ASAS) 20 criteria was the primary efficacy
measure. Functioning and HRQL were assessed by patient-reported
questionnaires, including Bath AS Functional Index (BASFI), SF-36
(Short Form-36) and Ankylosing Spondylitis Quality of Life
Questionnaire (ASQoL). Patient-reported questionnaires utilized in
this study are described in greater detail below.
[0241] The BASDAI is a six-item measure of disease activity and
includes questions on fatigue, spinal pain, peripheral arthritis,
enthesitis, and duration and severity of morning stiffness. It is a
well-established instrument widely used in clinical studies to
evaluate AS disease activity. Items are related to the past 7 days
and are answered on a 10 cm visual analogue scale (VAS), with score
ranges from 0 (none) to 10 (very severe). Instrument was
administered at Baseline, and at Weeks 2, 4, 8, 12, 16, 20 and
24.
[0242] The BASFI is a set of 10 questions designed to determine the
degree of functional limitation in those with AS. Items are related
to the past 7 days and are answered on a 10 cm visual analogue
scale (VAS). The score ranges from 0 to 100, with lower scores
reflecting less function limitation. Instrument was administered at
Baseline, and at Weeks 2, 4, 8, 12, 16, 20 and 24.
[0243] SF-36 is a widely applied instrument for measuring health
status and consists of 8 domains: physical function, bodily pain,
role limitations-physical, general health, vitality, social
function, role limitations-emotional, and mental health. The Recall
period is 4 weeks, and domain scores range from 0-100, with higher
scores reflecting better health status. A 5-10 point change in
domain scores is considered clinically meaningful (Kosinski M et
al. Arth Rheum 2000; 7:1478-1487). SF-36 also contains 2 summary
scores, the mental component summary (MCS) and the physical
component summary (PCS); a 2.5-5 point change in summary scores is
considered clinically meaningful (Kosinski M et al. Arth Rheum
2000; 7:1478-1487). This instrument was administered at Baseline,
and at Weeks 12 and 24.
[0244] The ASQoL is a disease-specific instrument designed to
measure HRQL in subjects with AS, developed on a needs-based model.
Subjects are asked to answer 18 yes/no items concerning the impact
of AS "at this moment". The ASQoL has a total score ranging from 0
to 18, with lower scores representing better AS-specific quality of
life. The instrument has good reliability and construct validity
across several different AS populations (Doward L C, et al. Ann
Rheum Dis 2003; 62:20-26; Haywood K L, et al J Rheumatol 2003;
30:764-773; van Tubergen A et al. Arthritis Rheum 2002; 47:8-16;
Marzo-Ortega H, et al. Arthritis Rheum 2001; 44(9):2112-2117). The
pre-specified minimum important difference (MID) has been suggested
to be a change of 1-2 points, 10% of the total score (Haywood K L,
et al J Rheumatol 2003; 30:764-773; Haywood K L, et al. Rheum 2002;
41:1295-1302). Assessments were made at Baseline and at Weeks 2,
12, and 24.
Results
[0245] A total of 315 subjects (adalimumab, N=208; placebo, N=107)
were enrolled. The disposition of subjects and study completion
rates are shown above in Table 13. At baseline, adalimumab and
placebo arms had comparable demographic and disease
characteristics, SF-36 (PCS, MCS), and ASQoL scores, as shown in
Table 12 above. Functioning and HRQOL assessment at baseline is
shown in Table 21. Baseline SF-36 PCS scores (placebo 31.7,
adalimumab 33.1) were almost 20 points lower than the U.S. general
population norm (50.0), indicating a substantial impairment of
physical health status, while baseline mental health status
measured by SF-36 MCS scores (placebo 44.7, adalimumab 43.5) were
close to the population norm.
TABLE-US-00021 TABLE 21 Functioning and HRQoL Assessment at
Baseline Adalimumab Placebo 40 mg eow (N = 107) (N = 208)
p-value.sup..dagger. SF-36 PCS 31.8 32.9 0.519 ASQoL 10.6 10.2
0.343 SF-36 MCS 44.4 43.4 0.407 SF-36 Subscales 0.495 Physical
Function 45.5 47.9 0.524 Role-Physical 19.9 20.5 0.214 Social
Function 53.4 57.2 0.323 General Health 41.0 43.4 0.491 Bodily Pain
29.8 31.7 0.544 Vitality 34.0 32.6 0.491 Role-Emotional 56.8 53.2
0.701 Mental Health 62.5 61.3 0.567 BSDAI Fatigue 6.7 6.5 0.846
*Unadjusted means .sup..dagger.Differences between treatment groups
were assessed using analysis of variance with treatment group and
baseline scores as covariates
[0246] At week 12 and 24, adalimumab treatment demonstrated
statistically significant ASAS20 response (the primary efficacy
measurement) compared with placebo, and the onset of improvement by
adalimumab was rapid and sustained (data is shown in FIG. 11). At
Week 12, adalimumab patients showed statistically significantly
greater improvement in SF-36 PCS scores than did placebo patients.
These statistically significant improvements increased through Week
24. Change in SF-36 PCS scores for adalimumab patients well
exceeded the MID value and suggested a sustained clinically
important improvement; placebo groups did not achieve the MID for
SF-36 PCS scores. The proportion of patients who achieved the MID
in SF-36 PCS scores was statistically significant in adalimumab vs.
placebo at 12 weeks (65.0 vs. 37.6, respectively, p.ltoreq.0.001)
and 24 weeks (67.3 vs. 39.6, respectively, p.ltoreq.0.001) (data is
shown in Table 22). Neither the adalimumab group nor the placebo
group experienced any significant change in MCS scores at Week 12
or Week 24. The proportion of patients that achieved the MID in
change of MCS scores was similar in both the adalimumab and placebo
groups.
TABLE-US-00022 TABLE 22 Change from Baseline in SF-36 PCS Scores at
12 Weeks and 24 Weeks Mean Change from Baseline.sup..dagger.
Placebo Adalimumab Week 12 1.6 6.9*** Week 24 1.9 7.4***
.sup..dagger.LOCF Minimum Important Difference = 3 (Kosinski M et
al. Arth Rheum 2000; 7: 1478-1487). ***Statistically significant at
p = 0.001 level. p-value for difference between therapies from
ANCOVA.
[0247] At both Weeks 12 and 24, patients treated with adalimumab
showed statistically significant improvement in 7 out of the 8
subscales compared with those treated with placebo, including the 4
subscales that are most closely related to the SF-36 PCS (Physical
Functioning, Role-Physical, Bodily Pain, and General Health) and 3
of the 4 subscales that are most closely related to the SF-36 MCS
(Vitality, Social Functioning, and Role-Emotional) (12-Week data is
shown in Table 23, 24-Week data is shown in Table 24). The
differences at Weeks 12 and 24 are also considered to be clinically
meaningful, based on the MID of 5-10 point change scores.
TABLE-US-00023 TABLE 23 Change from Baseline in SF-36 Domain Scores
at 12 Weeks.sup..dagger. Mean Change Placebo Adalimumab Physical
Functioning 3 11.8*** Role-Physical 7.9 25.3*** Social Functioning
6.3 8.7* General Health 1.4 8*** Bodily Pain 6.7 19.2*** Vitality
6.4 13.1** Role-Emotional 3.2 14.7* Mental Health 4.3 4.6
.sup..dagger.LOCF unadjusted means Differences between treatment
groups were assessed using an analysis of covariance with treatment
group and baseline scores as covariates. *, **, and *** are
statistically significant at the p < 0.05, p < 0.01, and p
< 0.001 levels, respectively.
TABLE-US-00024 TABLE 24 Change from Baseline in SF-36 Domain Scores
at 24 Weeks.sup..dagger. Mean Change Placebo Adalimumab Physical
Functioning 4.2 13.2*** Role-Physical 9.2 27.6*** Social
Functioning 6.5 12.2*** General Health 1.2 8.8*** Bodily Pain 7.1
20.7*** Vitality 5.6 14.7*** Role-Emotional 3.5 15.9* Mental Health
4.7 5.9 .sup..dagger.LOCF unadjusted means Differences between
treatment groups were assessed using an analysis of covariance with
treatment group and baseline scores as covariates. *, **, and ***
are statistically significant at the p < 0.05, p < 0.01, and
p < 0.001 levels, respectively.
[0248] More adalimumab patients experienced a statistically
significant improvement in BASFI compared with placebo patients at
Week 12 and Week 24 (data is shown in Table 25).
TABLE-US-00025 TABLE 25 Change from Baseline in BASFI Scores at 12
Weeks and 24 Weeks.sup..dagger. Mean Change at Baseline.dagger-dbl.
Placebo Adalimumab Week 12 -5.05 -17.46*** Week 24 -5.16 -18.7***
.sup..dagger.LOCF .dagger-dbl.unadjusted means ***Statistically
significant at the pp < 0.001, placebo vs. adalimumab. p-value
for differences between therapies from an ANCOVA with therapy and
baseline values as a covariate.
[0249] At Week 12 and Week 24, adalimumab patients showed greater
improvement in overall HRQL as measured by ASQoL scores when
compared to placebo patients (data is shown in Table 26). The
change in ASQoL scores exceeded the prior MID value and suggested a
sustained clinically important improvement. The proportion of
adalimumab patients that achieved the MID in ASQoL score was
statistically significantly higher than the proportion of placebo
patients. The proportion of patients who achieved the MID in ASQoL
scores was statistically significant in adalimumab vs. placebo at
12 weeks (59.1 vs. 42.1, respectively, p<0.01) and 24 weeks
(65.4 vs. 42.1, respectively, p<0.001).
TABLE-US-00026 TABLE 26 Change from Baseline in ASQoL Scores at 12
Weeks and 24 Weeks.sup..dagger. Mean Change at Baseline.dagger-dbl.
Placebo Adalimumab Week 12 -1.0 -3.1*** Week 24 -1.1 -3.6***
.sup..dagger.LOCF .dagger-dbl.unadjusted means Minimum Important
Difference = -2 (Haywood K. L. et al. J. Rheumatol. 2003; 30:
764-773; Haywood K. L. et al. Rheum. 2002; 41: 1295-1302).
***Statistically significant at the p = 0.001 level, p-value
assessed using analysis of variance within treatment group and
baseline scores as covariates.
Conclusions
[0250] These results suggest that adalimumab therapy may improve
physical health status and overall HRQL in AS patients. After 12
and 24 weeks of adalimumab therapy, patients reported statistically
significant and clinically meaningful improvements in physical
functioning as measured by SF-36 PCS and BASFI compared with
placebo. At 12 and 24 weeks, patients treated with adalimumab
reported statistically significant and clinically meaningful
improvements in overall HRQL as measured by ASQoL compared with
those treated with placebo.
Example 6
Adalimumab Therapy Results in Significant Reduction of Signs and
Symptoms in Subjects with Ankylosing Spondylitis
[0251] The aim of the following study (Study H) was to assess the
efficacy and safety of adalimumab in the treatment of AS. The study
design of Study H is outlined in FIG. 7, and included a
double-blind placebo-controlled 24 week study followed by a
continuous open label study (shown in FIG. 7). Details regarding
Study H are also provided in the above examples referencing this
study, as well as below.
[0252] Inclusion criteria were the following: .gtoreq.18 years of
age; AS based on modified New York criteria; inadequate response to
.gtoreq.1 NSAID; and active AS, as diagnosed by 2 of the 3
following symptoms: Bath AS Disease Activity Index (BASDAI) score
.gtoreq.4; Visual Analog Scale (VAS) score for Total Back Pain
(TBP).gtoreq.4; and Morning stiffness .gtoreq.1 hour. Patients not
achieving an ASAS 20 response after 12 weeks were eligible for
early escape therapy (EET) of open-label 40 mg adalimumab eow. Any
patient receiving EET was treated as a nonresponder at all
subsequent visits in the statistical analysis.
[0253] The primary endpoint for monitoring reduction of signs and
symptoms was ASAS 20 at Week 12. Major secondary endpoints were
ASAS 40, ASAS 5/6, and ASAS Partial Remission Criteria. Outcome
measures were assessed at Weeks 12 and 24.
[0254] ASAS20 improvement criteria included assessment of patient
global, pain, function, and inflammation, and required an
improvement of .gtoreq.20% and .gtoreq.1 unit in at least 3 of
these domains, without a worsening of .gtoreq.20% and .gtoreq.1
unit in the remaining domain (see Anderson et al. (2001) Arthritis
Rheum 44:1876-1886).
[0255] ASAS 40 improvement criteria included an assessment of the
same four domains as for ASAS20, and required an improvement of
.gtoreq.40% and .gtoreq.2 units in at least 3 domains, with no
worsening at all in the remaining domain (see Brandt et al. (2004)
Ann Rheum 63:1438-1444).
[0256] ASAS 5/6 improvement criteria included an improvement of
.gtoreq.20% in at least 5 of the following 6 domains: patient
global, pain, function, inflammation, CRP, and spinal mobility (see
Brandt et al. (2004) Ann Rheum 63:1438-1444).
[0257] ASAS partial remission criteria include a value of <2
units in all four of the following domains: patient global, pain,
function, and inflammation (see Anderson et al. (2001) Arthritis
Rheum 44:1876-1886).
[0258] Baseline demographics are shown in Table 12 above, and
concomitant diseases or symptoms present at baseline are shown in
Table 27.
TABLE-US-00027 TABLE 27 Concomitant Diseases or Symptoms at
Baseline Adalimumab Placebo 40 mg eow (N = 107) (N = 208) n (%) n
(%) History of inflammatory bowel 6 (5.6) 21 (10.1) disease.dagger.
Peripheral arthritis.dagger-dbl. 44 (44.1) 75 (36.1) History of
psoriasis.dagger. 17 (15.9) 16 (7.7) History of uveitis.dagger. 27
(25.2) 68 (32.7) *No significant differences between groups except
for psoriasis .sup..dagger.Stable for at least four weeks prior to
Baseline .sup..dagger-dbl.At least one SJC at Baseline
[0259] Baseline disease activity is shown in Table 28. Concomitant
Treatment at baseline is shown in Table 29. The disposition of
subjects in the trial is shown above in Table 13. Patients
receiving early escape open-label therapy are shown in Table
30.
TABLE-US-00028 TABLE 28 Baseline Disease Activity Adalimumab
Placebo 40 mg eow (N = 107) (N = 208) BASDAI score* 6.3 6.3 BASDAI
categories.sup..dagger. <4 12 (11.2) 25 (12.0) 4-6 30 (28.0) 62
(29.8) >6 65 (60.7) 121 (58.2) Total Back Pain VAS 6.7 6.4
Morning Stiffness 6.7 6.7 BASFI score* 5.6 5.2 CRP (mg/dL)* 2.2 1.8
Patients with elevated CRP.sup..dagger..dagger-dbl. 75 (70.1) 138
(66.3) *Mean .sup..dagger.n (%) .sup..dagger-dbl.Normal CRP
range.ltoreq.0.494 mg/dl
TABLE-US-00029 TABLE 29 Concomitant Treatment at Baseline
Adalimumab Placebo 40 mg eow (N = 107) (N = 208) Baseline DMARD
use* 22 (20.6) 40 (19.2) Methotrexate 8 (7.5) 20 (9.6)
Sulfasalazine 15 (14.0) 26 (12.5) Leflunomide 1 (0.9) 0 Oral
corticosteroids 6 (5.6) 25 (12.0) NSAIDs 84 (78.5) 166 (79.8) *n
(%)
TABLE-US-00030 TABLE 30 Patients Receiving Early Escape Open-label
Therapy Adalimumab Placebo 40 mg eow (N = 107) (N = 208) Visit n
(%) n (%) Total 74 (69.2) 81 (38.9) Week 12 55 (51.4) 54 (26.0)
Week 14 11 (10.3) 5 (2.4) Week 16 6 (5.6) 10 (4.8) Week 18 0 (0.0)
1 (0.5) Week 20 2 (1.9) 8 (3.8) Week 22 0 (0.0) 3 (1.4)
[0260] A statistically significant change from baseline was
observed between the adalimumab and placebo patient treatment
groups in the following ASAS20 components: patient's global
assessment of disease activity, total back pain, and inflammation.
The baseline mean score for patient's global assessment of disease
activity was 64.5 for the placebo treatment group and 63.2 for the
adalimumab treatment group. The percentage change from baseline
observed in the placebo group was 6.5 at Week 12, and 8.7 at Week
24 (N=107). The percentage change from baseline observed in the
adalimumab group was -39.1 at Week 12, and -37.8 at Week 24 (N=208;
difference between placebo vs. adalimumab is significant at p=0.001
level, determined by ANCOVA).
[0261] The baseline mean score for total back pain was 67.2 for the
placebo treatment group and 64.6 for the adalimumab treatment
group. The percentage change from baseline observed in the placebo
group was -9.5 at Week 12 and -10.0 at Week 24 (N=107). The
percentage change from baseline observed in the adalimumab group
was -40.5 at Week 12, and -42.4 at Week 24 (N=208; difference
between placebo vs. adalimumab is significant at p=0.001 level,
determined by ANCOVA).
[0262] The baseline mean score for inflammation (the mean of BASDAI
questions 5 and 6) was 6.7 for both the placebo and adalimumab
treatment groups. The percentage change from baseline observed in
the placebo group was -15.2 at Week 12 and -12.5 at Week 24
(N=107). The percentage change from baseline observed in the
adalimumab group was -41.7 at Week 12, and -42.9 at Week 24 (N=208;
difference between placebo vs. adalimumab is significant at p=0.001
level, determined by ANCOVA).
[0263] The mean change in ASAS 20, ASAS 40, and ASAS 5/6 from
baseline at Week 12 and Week 24 is shown in Table 31. BASDAI 50 at
Week 12 and Week 24 is shown in Table 32.
TABLE-US-00031 TABLE 31 ASAS20.dagger., ASAS40.dagger-dbl., and
ASAS 5/6.dagger-dbl. Mean Change from Baseline ASAS20 ASAS40
ASAS5/6 Week 12 Placebo 20.6 14.0 13.1 Adalimumab 58.2*** 40.9***
48.6*** Week 24 Placebo 18.7 14.0 12.1 Adalimumab 50.5*** 39.4***
44.7*** .dagger.Imputed; .dagger-dbl.LOCF ***Statistically
significant at p < 0.001 level (ANCOVA)
TABLE-US-00032 TABLE 32 BASDAI 50 % of Patients Placebo Adalimumab
(N = 107) (N = 208) Week 12 15.9 45.2*** Week 24 15.0 42.3***
***Statistically significant at p = 0.001 level (Pearson's
Chi-Square test). Patients with missing data at Weeks 12 and 24 are
counted as non-responders.
[0264] The percentage of patients achieving partial remission at
Week 12 and Week 24 is shown in Table 33. The mean change in
BASDAI, BASFI, and BASAMI from baseline at Week 24 is shown in
Table 34.
TABLE-US-00033 TABLE 33 Partial Remission.dagger-dbl. Partial
Remission % of Patients.dagger. Placebo Adalimumab (N = 107) (N =
208) Week 12 3.7 20.7*** Week 24 5.6 22.1*** .dagger.LOCF;
.dagger-dbl.Partial remission is defined as a value <20 on a
0-100 scale in each of the four ASAS domains. ***Statistically
significant at p = 0.001 level (Pearson's Chi-Square test).
TABLE-US-00034 TABLE 34 BASDAI, BASFI, and BASMI at Week 24 Mean
change from Baseline Placebo Adalimumab BASDAI -0.8 -2.6*** BASFI
-0.5 -1.87*** BASMI 0.0 -0.6 .dagger.LOCF ***Statistically
significant at p < 0.001 level (ANCOVA)
[0265] A Subgroup Analysis of ASAS 20 responders with Total Spinal
Ankylosis is shown in Table 35.
TABLE-US-00035 TABLE 35 Subgroup Analysis-Total Spinal Ankylosis
ASAS20 Responders (% of Patients) Yes No Week 12 Placebo 0 (n = 5)
21.6 (n = 102) Adalimumab 50 (n = 6) 58.2 (n = 201) Week 24 Placebo
0 (n = 5) 19.6 (n = 102) Adalimumab 66.7 (n = 6) 49.8 (n = 201)
[0266] The Maastricht AS Enthesitis Score (MASES), which assesses
the patients response to firm palpation at 13 points in the chest,
hip, and foot regions, was measured at Weeks 12 and 24. Possible
total scores range from 0-13, with a score of 0 indicating no pain,
and a score of 1 indicating pain. Consequently, a decrease in MASES
is representative of improvement. The mean baseline MASES was 6.7
in the placebo treatment group, and 6.3 in the adalimumab treatment
group. The mean change from baseline MASES (LOCF) in the placebo
group was -1.3 at Week 12 and -1.6 at Week 24 (N=106). The mean
change from baseline MASES in the adalimumab group was -2.7 at Week
12 (N=204; statistically significant at p<0.05 vs. placebo as
determined by ANCOVA), and -3.2 at Week 24 (N=205; statistically
significant at p<0.01 vs. placebo as determined by ANCOVA).
[0267] Adverse events with a .gtoreq.5% incidence through Week 24
are shown in Table 36. Treatment-emergent adverse events through
week 24 are shown in Table 37.
TABLE-US-00036 TABLE 36 Adverse Events .gtoreq.5% Incidence Through
Week 24.sup..dagger. Adalimumab Placebo 40 mg eow (N = 107) (N =
208) MedDRA preferred term: n (%) n (%) P-value.dagger-dbl.
Nasopharyngitis 8 (7.5) 26 (12.5) 0.249 Injection site reaction 3
(2.8) 22 (10.6) 0.015* Headache 9 (8.4) 20 (9.6) 0.838
.sup..dagger.During administration of blinded study medication
.sup..dagger-dbl.Fischer's exact test (2 tail) *Statistically
significant at p .ltoreq. 0.05 level
TABLE-US-00037 TABLE 37 Treatment-emergent Adverse Events (AEs)
Through Week 24.sup..dagger. Adalimumab Placebo 40 mg eow (N = 107)
(N = 208) Patients with: n (%) n (%) p-value.sup..dagger-dbl. Any
AE 66 (61.7) 163 (78.4) 0.002** Serious AE 3 (2.8) 6 (2.9) NS
Severe AE 4 (3.7) 6 (2.9) NS AE leading to discontinuation 2 (1.9)
4 (1.9) NS of study drug AE at least possibly 18 (16.8) 74 (35.6)
<0.001*** drug-related Infections AE 24 (22.4) 70 (33.7) NS
Serious infectious AE 1 (0.9) 0 (0.0) NS Drug hypersensitivity
reaction 1 (0.9) 1 (0.4) NS Malignant neoplasm 0 (0.0) 0 (0.0) NS
Death 0 (0.0) 0 (0.0) NS .sup..dagger.During administration of
blinded study medication .sup..dagger-dbl.Only statistically
significant p-values are shown **, ***Statistically significant at
the p = 0.01 and p = 0.001 levels, respectively (Pearson's
Chi-Square test)
[0268] Laboratory tests were performed through Week 24. There were
small changes in hemoglobin, platelets, neutrophils and lymphocyte
counts in adalimumab-treated patients. Adalimumab patients had
significantly higher levels of liver enzymes (ALT, AST) and total
bilirubin compared with placebo; however, these changes were small.
Baseline and maximum ALT values through Week 24 are shown in Table
38. Adalimumab patients also had a significantly greater decrease
in C-reactive protein (CRP) at Weeks 12 and 24. The baseline mean
CRP was 2.16 mg/dL in the placebo treatment group and 1.76 mg/dL in
the adalimumab treatment group. The mean change from baseline
(LOCF) in CRP (mg/dL) among patients in the placebo group was -0.08
at Week 12 and -0.06 at Week 24 (N=105). The mean change from
baseline among patients in the adalimumab group was -1.28 at Week
12 and -1.25 at Week 24 (N=204; statistically significant vs.
placebo at p.ltoreq.0.001 level as determined by ANCOVA).
TABLE-US-00038 TABLE 38 Baseline and Maximum ALT Values Through
Week 24 Maximum ALT Value <1.5 .times. .gtoreq.1.5 .times.
ULN-<3.0 .times. .gtoreq.3.0 .times. ULN-<8.0 .times.
.gtoreq.8.0 .times. ULN ULN ULN ULN Baseline ALT Value n (%) n (%)
n (%) n (%) Placebo (N = 107) <1.5 .times. ULN 104 (97.2) 2
(1.9) 0 0 .gtoreq.1.5 .times. ULN-<3.0 .times. ULN 0 0 0 0
.gtoreq.3.0 .times. ULN-<8.0 .times. ULN 0 1 (0.9) 0 0
.gtoreq.8.0 .times. ULN 0 0 0 0 Adalimumab 40 mg eow (N = 208)
<1.5 .times. ULN 175 (84.1) 23 (11.1) 2 (1.0) 1 (0.5)
.gtoreq.1.5 .times. ULN-<3.0 .times. ULN 1 (0.5) 1 (0.5) 3 (1.4)
0 .gtoreq.3.0 .times. ULN-<8.0 .times. ULN 0 2 (1.0) 0 0
.gtoreq.8.0 .times. ULN 0 0 0 0
Conclusions
[0269] Adalimumab was generally well tolerated in patients with
active AS. The safety profile of adalimumab in the Study H Trial
was consistent with that observed in RA and PsA trials. Adalimumab
was effective in treating subjects with active AS. Adalimumab
showed similar efficacy in patients with and without Total Spinal
Ankylosis (TSA).
EQUIVALENTS
[0270] Those skilled in the art will recognize, or be able to
ascertain using no more than routine experimentation, many
equivalents to the specific embodiments of the invention described
herein. Such equivalents are intended to be encompassed by the
following claims. The contents of all references, patents and
published patent applications cited throughout this application are
incorporated herein by reference.
Sequence CWU 1
1
371107PRTArtificialD2E7 light chain variable region 1Asp Ile Gln
Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly1 5 10 15Asp Arg
Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Tyr 20 25 30Leu
Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40
45Tyr Ala Ala Ser Thr Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly
50 55 60Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln
Pro65 70 75 80Glu Asp Val Ala Thr Tyr Tyr Cys Gln Arg Tyr Asn Arg
Ala Pro Tyr 85 90 95Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100
1052121PRTArtificialD2E7 heavy chain variable region 2Glu Val Gln
Leu Val Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Arg1 5 10 15Ser Leu
Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Asp Asp Tyr 20 25 30Ala
Met His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40
45Ser Ala Ile Thr Trp Asn Ser Gly His Ile Asp Tyr Ala Asp Ser Val
50 55 60Glu Gly Arg Phe Thr Ile Ser Arg Asp Asn Ala Lys Asn Ser Leu
Tyr65 70 75 80Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val
Tyr Tyr Cys 85 90 95Ala Lys Val Ser Tyr Leu Ser Thr Ala Ser Ser Leu
Asp Tyr Trp Gly 100 105 110Gln Gly Thr Leu Val Thr Val Ser Ser 115
12039PRTArtificialD2E7 light chain variable region CDR3 3Gln Arg
Tyr Asn Arg Ala Pro Tyr Xaa1 5412PRTArtificialD2E7 heavy chain
variable region CDR3 4Val Ser Tyr Leu Ser Thr Ala Ser Ser Leu Asp
Xaa1 5 1057PRTArtificialD2E7 light chain variable region CDR2 5Ala
Ala Ser Thr Leu Gln Ser1 5617PRTArtificialD2E7 heavy chain variable
region CDR2 6Ala Ile Thr Trp Asn Ser Gly His Ile Asp Tyr Ala Asp
Ser Val Glu1 5 10 15Gly711PRTArtificialD2E7 light chain variable
region CDR1 7Arg Ala Ser Gln Gly Ile Arg Asn Tyr Leu Ala1 5
1085PRTArtificialD2E7 heavy chain variable region CDR1 8Asp Tyr Ala
Met His1 59107PRTArtificial2SD4 light chain variable region 9Asp
Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Ile Gly1 5 10
15Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Tyr
20 25 30Leu Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu
Ile 35 40 45Tyr Ala Ala Ser Thr Leu Gln Ser Gly Val Pro Ser Arg Phe
Ser Gly 50 55 60Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser
Leu Gln Pro65 70 75 80Glu Asp Val Ala Thr Tyr Tyr Cys Gln Lys Tyr
Asn Ser Ala Pro Tyr 85 90 95Ala Phe Gly Gln Gly Thr Lys Val Glu Ile
Lys 100 10510121PRTArtificial2SD4 heavy chain variable region 10Gln
Val Gln Leu Val Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Arg1 5 10
15Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Asp Asp Tyr
20 25 30Ala Met His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Asp Trp
Val 35 40 45Ser Ala Ile Thr Trp Asn Ser Gly His Ile Asp Tyr Ala Asp
Ser Val 50 55 60Glu Gly Arg Phe Ala Val Ser Arg Asp Asn Ala Lys Asn
Ala Leu Tyr65 70 75 80Leu Gln Met Asn Ser Leu Arg Pro Glu Asp Thr
Ala Val Tyr Tyr Cys 85 90 95Thr Lys Ala Ser Tyr Leu Ser Thr Ser Ser
Ser Leu Asp Asn Trp Gly 100 105 110 Gln Gly Thr Leu Val Thr Val Ser
Ser 115 120119PRTArtificial2SD4 light chain variable region CDR3
11Gln Lys Tyr Asn Ser Ala Pro Tyr Ala1 5129PRTArtificialEP B12
light chain variable region CDR3 12Gln Lys Tyr Asn Arg Ala Pro Tyr
Ala1 5139PRTArtificialVL10E4 light chain variable region CDR3 13Gln
Lys Tyr Gln Arg Ala Pro Tyr Thr1 5149PRTArtificialVL100A9 light
chain variable region CDR3 14Gln Lys Tyr Ser Ser Ala Pro Tyr Thr1
5159PRTArtificialVLL100D2 light chain variable region CDR3 15Gln
Lys Tyr Asn Ser Ala Pro Tyr Thr1 5169PRTArtificialVLL0F4 light
chain variable region CDR3 16Gln Lys Tyr Asn Arg Ala Pro Tyr Thr1
5179PRTArtificialLOE5 light chain variable region CDR3 17Gln Lys
Tyr Asn Ser Ala Pro Tyr Tyr1 5189PRTArtificialVLLOG7 light chain
variable region CDR3 18Gln Lys Tyr Asn Ser Ala Pro Tyr Asn1
5199PRTArtificialVLLOG9 light chain variable region CDR3 19Gln Lys
Tyr Thr Ser Ala Pro Tyr Thr1 5209PRTArtificialVLLOH1 light chain
variable region CDR3 20Gln Lys Tyr Asn Arg Ala Pro Tyr Asn1
5219PRTArtificialVLLOH10 light chain variable region CDR3 21Gln Lys
Tyr Asn Ser Ala Ala Tyr Ser1 5229PRTArtificialVL1B7 light chain
variable region CDR3 22Gln Gln Tyr Asn Ser Ala Pro Asp Thr1
5239PRTArtificialVL1C1 light chain variable region CDR3 23Gln Lys
Tyr Asn Ser Asp Pro Tyr Thr1 5249PRTArtificialVL0.1F4 light chain
variable region CDR3 24Gln Lys Tyr Ile Ser Ala Pro Tyr Thr1
5259PRTArtificialVL0.1H8 light chain variable region CDR3 25Gln Lys
Tyr Asn Arg Pro Pro Tyr Thr1 5269PRTArtificialLOE7.A light chain
variable region CDR3 26Gln Arg Tyr Asn Arg Ala Pro Tyr Ala1
52712PRTArtificial2SD4 heavy chain variable region CDR3 27Ala Ser
Tyr Leu Ser Thr Ser Ser Ser Leu Asp Asn1 5
102812PRTArtificialVH1B11 heavy chain variable region CDR3 28Ala
Ser Tyr Leu Ser Thr Ser Ser Ser Leu Asp Lys1 5
102912PRTArtificialVH1D8 heavy chain variable region CDR3 29Ala Ser
Tyr Leu Ser Thr Ser Ser Ser Leu Asp Tyr1 5
103012PRTArtificialVH1A11 heavy chain variable region CDR3 30Ala
Ser Tyr Leu Ser Thr Ser Ser Ser Leu Asp Asp1 5
103112PRTArtificialVH1B12 heavy chain variable region CDR3 31Ala
Ser Tyr Leu Ser Thr Ser Phe Ser Leu Asp Tyr1 5
103212PRTArtificialVH1E4 heavy chain variable region CDR3 32Ala Ser
Tyr Leu Ser Thr Ser Ser Ser Leu His Tyr1 5 103312PRTArtificialVH1F6
heavy chain variable region CDR3 33Ala Ser Phe Leu Ser Thr Ser Ser
Ser Leu Glu Tyr1 5 103412PRTArtificial3C-H2 heavy chain variable
region CDR3 34Ala Ser Tyr Leu Ser Thr Ala Ser Ser Leu Glu Tyr1 5
103512PRTArtificialVH1-D2.N heavy chain variable region CDR3 35Val
Ser Tyr Leu Ser Thr Ala Ser Ser Leu Asp Asn1 5
1036321DNAArtificialD2E7 light chain variable region 36gacatccaga
tgacccagtc tccatcctcc ctgtctgcat ctgtagggga cagagtcacc 60atcacttgtc
gggcaagtca gggcatcaga aattacttag cctggtatca gcaaaaacca
120gggaaagccc ctaagctcct gatctatgct gcatccactt tgcaatcagg
ggtcccatct 180cggttcagtg gcagtggatc tgggacagat ttcactctca
ccatcagcag cctacagcct 240gaagatgttg caacttatta ctgtcaaagg
tataaccgtg caccgtatac ttttggccag 300gggaccaagg tggaaatcaa a
32137363DNAArtificialD2E7 heavy chain variable region 37gaggtgcagc
tggtggagtc tgggggaggc ttggtacagc ccggcaggtc cctgagactc 60tcctgtgcgg
cctctggatt cacctttgat gattatgcca tgcactgggt ccggcaagct
120ccagggaagg gcctggaatg ggtctcagct atcacttgga atagtggtca
catagactat 180gcggactctg tggagggccg attcaccatc tccagagaca
acgccaagaa ctccctgtat 240ctgcaaatga acagtctgag agctgaggat
acggccgtat attactgtgc gaaagtctcg 300taccttagca ccgcgtcctc
ccttgactat tggggccaag gtaccctggt caccgtctcg 360agt 363
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