U.S. patent application number 15/148491 was filed with the patent office on 2016-11-03 for methods and compositions for treating complement-associated disorders.
The applicant listed for this patent is Alexion Pharmaceuticals, Inc.. Invention is credited to Camille Bedrosian, Leonard Bell, Russell P. Rother, Stephen P. Squinto.
Application Number | 20160319004 15/148491 |
Document ID | / |
Family ID | 42153320 |
Filed Date | 2016-11-03 |
United States Patent
Application |
20160319004 |
Kind Code |
A1 |
Rother; Russell P. ; et
al. |
November 3, 2016 |
METHODS AND COMPOSITIONS FOR TREATING COMPLEMENT-ASSOCIATED
DISORDERS
Abstract
The present disclosure relates to, inter alia, compositions
containing an inhibitor of human complement and use of the
compositions in methods for treating or preventing
complement-associated disorders. In some embodiments, the inhibitor
is chronically administered to patients. In some embodiments, the
inhibitor is administered to a patient in an amount and with a
frequency to maintain systemic complement inhibition and prevent
breakthrough. In some embodiments, the compositions contain an
antibody, or antigen-binding fragment thereof, that binds to a
human complement component C5 protein or a fragment of the protein
such as C5a or C5b.
Inventors: |
Rother; Russell P.;
(Oklahoma City, OK) ; Bedrosian; Camille;
(Woodbridge, CT) ; Squinto; Stephen P.; (Bethany,
CT) ; Bell; Leonard; (Woodbridge, CT) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Alexion Pharmaceuticals, Inc. |
New Haven |
CT |
US |
|
|
Family ID: |
42153320 |
Appl. No.: |
15/148491 |
Filed: |
May 6, 2016 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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13128523 |
Oct 25, 2011 |
9447176 |
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PCT/US2009/063929 |
Nov 10, 2009 |
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15148491 |
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61200640 |
Dec 1, 2008 |
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61199562 |
Nov 18, 2008 |
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61199563 |
Nov 18, 2008 |
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61181788 |
May 28, 2009 |
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61199569 |
Nov 18, 2008 |
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61200635 |
Dec 1, 2008 |
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61199764 |
Nov 19, 2008 |
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61228047 |
Jul 23, 2009 |
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61200634 |
Dec 1, 2008 |
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61198803 |
Nov 10, 2008 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 39/3955 20130101;
C07K 2317/34 20130101; A61K 2039/54 20130101; C07K 16/18 20130101;
A61P 7/04 20180101; A61P 9/14 20180101; A61P 21/02 20180101; A61P
13/12 20180101; A61P 9/12 20180101; A61P 7/02 20180101; A61P 43/00
20180101; A61K 2039/545 20130101; A61P 37/06 20180101; A61K 45/06
20130101; C07K 2317/24 20130101; A61K 38/00 20130101; A61K 2039/505
20130101; A61P 9/00 20180101; A61P 21/04 20180101; A61P 37/02
20180101; A61K 9/0019 20130101 |
International
Class: |
C07K 16/18 20060101
C07K016/18; A61K 9/00 20060101 A61K009/00; A61K 39/395 20060101
A61K039/395; A61K 45/06 20060101 A61K045/06 |
Claims
1-93. (canceled)
94-128. (canceled)
129. A method for treating myasthenia gravis (MG) in an anti-AChR
antibody positive patient, the method comprising administering
eculizumab to a patient in need thereof in an amount effective to
treat MG in the patient; wherein the administration schedule of
eculizumab comprises the following: at least 600 mg of eculizumab
once per week for the first four consecutive weeks of treatment;
and a maintenance dose of at least 900 mg of eculizumab every two
weeks.
130. The method of claim 129, wherein the eculizumab is
administered to the patient in an amount and with a frequency to
maintain at least 50 .mu.g of eculizumab per milliliter of the
patient's blood.
131. The method of claim 129, wherein the eculizumab is
administered to the patient in an amount and with a frequency to
maintain at least 100 .mu.g of eculizumab per milliliter of the
patient's blood.
132. The method of claim 129, wherein the patient exhibits a
substantial improvement in at least two symptoms of MG during the
first four weeks of treatment.
133. The method of claim 129, wherein the maintenance dose of
eculizumab is administered every two weeks until the patient's MG
is in remission.
134. A method for treating myasthenia gravis (MG) in an anti-AChR
antibody positive patient, the method comprising administering
eculizumab to a patient in need thereof in an amount effective to
treat MG in the patient; wherein the eculizumab is intravenously
administered to the patient under the following schedule: 900 mg of
eculizumab once per week for four consecutive weeks; 1200 mg of
eculizumab on the fifth week; and 1200 mg of eculizumab every two
weeks thereafter.
135. The method of claim 134, wherein the eculizumab is
administered to the patient in an amount and with a frequency to
maintain at least 50 .mu.g of eculizumab per milliliter of the
patient's blood.
136. The method of claim 134, wherein the eculizumab is
administered to the patient in an amount and with a frequency to
maintain at least 100 .mu.g of eculizumab per milliliter of the
patient's blood.
137. The method of claim 134, wherein the patient exhibits a
substantial improvement in at least two symptoms of MG during the
first four weeks of treatment.
138. The method of claim 134, wherein the maintenance dose of
eculizumab is administered every two weeks until the patient's MG
is in remission.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application is a continuation of U.S. application Ser.
No. 13/128,523, filed on Oct. 25, 2011, which is the National Stage
Entry of International Application No. PCT/US09/063929, filed on
Nov. 10, 2009, which claims the benefit of U.S. Provisional Patent
Application Ser. No. 61/198,803, filed on Nov. 10, 2008;
61/199,563, filed on Nov. 18, 2008; 61/199,562, filed on Nov. 18,
2008; 61/199,569, filed on Nov. 18, 2008; 61/199,764, filed on Nov.
19, 2008; 61/200,640, filed on Dec. 1, 2008; 61/200,634, filed on
Dec. 1, 2008; 61/200,635, filed on Dec. 1, 2008; 61/181,788, filed
on May 28, 2009; and 61/228,047, filed on Jul. 23, 2009. The
disclosures of each of these patents and patent applications are
hereby incorporated by reference in their entirety.
TECHNICAL FIELD
[0002] The field of the invention is medicine, immunology,
molecular biology, and protein chemistry.
BACKGROUND
[0003] The complement system acts in conjunction with other
immunological systems of the body to defend against intrusion of
cellular and viral pathogens. There are at least 25 complement
proteins, which are found as a complex collection of plasma
proteins and membrane cofactors. The plasma proteins make up about
10% of the globulins in vertebrate serum. Complement components
achieve their immune defensive functions by interacting in a series
of intricate but precise enzymatic cleavage and membrane binding
events. The resulting complement cascade leads to the production of
products with opsonic, immunoregulatory, and lytic functions. A
concise summary of the biologic activities associated with
complement activation is provided, for example, in The Merck
Manual, 16.sup.th Edition.
[0004] The complement cascade can progress via the classical
pathway (CP), the lectin pathway, or the alternative pathway (AP).
The lectin pathway is typically initiated with binding of
mannose-binding lectin (MBL) to high mannose substrates. The AP can
be antibody independent, and can be initiated by certain molecules
on pathogen surfaces. The CP is typically initiated by antibody
recognition of, and binding to, an antigenic site on a target cell.
These pathways converge at the C3 convertase--the point where
complement component C3 is cleaved by an active protease to yield
C3a and C3b.
[0005] The AP C3 convertase is initiated by the spontaneous
hydrolysis of complement component C3, which is abundant in the
plasma in the blood. This process, also known as "tickover," occurs
through the spontaneous cleavage of a thioester bond in C3 to form
C3i or C3(H.sub.2O). Tickover is facilitated by the presence of
surfaces that support the binding of activated C3 and/or have
neutral or positive charge characteristics (e.g., bacterial cell
surfaces). This formation of C3(H.sub.2O) allows for the binding of
plasma protein Factor B, which in turn allows Factor D to cleave
Factor B into Ba and Bb. The Bb fragment remains bound to C3 to
form a complex containing C3(H.sub.2O)Bb--the "fluid-phase" or
"initiation" C3 convertase. Although only produced in small
amounts, the fluid-phase C3 convertase can cleave multiple C3
proteins into C3a and C3b and results in the generation of C3b and
its subsequent covalent binding to a surface (e.g., a bacterial
surface). Factor B bound to the surface-bound C3b is cleaved by
Factor D to thus form the surface-bound AP C3 convertase complex
containing C3b,Bb. (See, e.g., Muller-Eberhard (1988) Ann Rev
Biochem 57:321-347.)
[0006] The AP C5 convertase--(C3b).sub.2,Bb--is formed upon
addition of a second C3b monomer to the AP C3 convertase. (See,
e.g., Medicus et al. (1976) J Exp Med 144:1076-1093 and Fearon et
al. (1975) J Exp Med 142:856-863.) The role of the second C3b
molecule is to bind C5 and present it for cleavage by Bb. (See,
e.g., Isenman et al. (1980) J Immunol 24:326-331.) The AP C3 and C5
convertases are stabilized by the addition of the trimeric protein
properdin as described in, e.g., Medicus et al. (1976), supra.
However, properdin binding is not required to form a functioning
alternative pathway C3 or C5 convertase. (See, e.g., Schreiber et
al. (1978) Proc Natl Acad Sci USA 75: 3948-3952 and Sissons et al.
(1980) Proc Natl Acad Sci USA 77: 559-562.)
[0007] The CP C3 convertase is formed upon interaction of
complement component C1, which is a complex of C1q, C1r, and C1s,
with an antibody that is bound to a target antigen (e.g., a
microbial antigen). The binding of the C1q portion of C1 to the
antibody-antigen complex causes a conformational change in C1 that
activates C1r. Active C1r then cleaves the C1-associated C1s to
thereby generate an active serine protease. Active C1s cleaves
complement component C4 into C4b and C4a. Like C3b, the newly
generated C4b fragment contains a highly reactive thiol that
readily forms amide or ester bonds with suitable molecules on a
target surface (e.g., a microbial cell surface). C1s also cleaves
complement component C2 into C2b and C2a. The complex formed by C4b
and C2a is the CP C3 convertase, which is capable of processing C3
into C3a and C3b. The CP C5 convertase--C4b,C2a,C3b--is formed upon
addition of a C3b monomer to the CP C3 convertase. (See, e.g.,
Muller-Eberhard (1988), supra and Cooper et al. (1970) J Exp Med
132:775-793.)
[0008] In addition to its role in C3 and C5 convertases, C3b also
functions as an opsonin through its interaction with complement
receptors present on the surfaces of antigen-presenting cells such
as macrophages and dendritic cells. The opsonic function of C3b is
generally considered to be one of the most important anti-infective
functions of the complement system. Patients with genetic lesions
that block C3b function are prone to infection by a broad variety
of pathogenic organisms, while patients with lesions later in the
complement cascade sequence, i.e., patients with lesions that block
C5 functions, are found to be more prone only to Neisseria
infection, and then only somewhat more prone.
[0009] The AP and CP C5 convertases cleave C5, which is a 190 kDa
beta globulin found in normal serum at approximately 75 .mu.g/ml
(0.4 .mu.M). C5 is glycosylated, with about 1.5-3 percent of its
mass attributed to carbohydrate. Mature C5 is a heterodimer of a
999 amino acid 115 kDa alpha chain that is disulfide linked to a
655 amino acid 75 kDa beta chain. C5 is synthesized as a single
chain precursor protein product of a single copy gene (Haviland et
al. (1991) J. Immunol. 146:362-368). The cDNA sequence of the
transcript of this gene predicts a secreted pro-C5 precursor of
1658 amino acids along with an 18 amino acid leader sequence (see,
e.g., U.S. Pat. No. 6,355,245).
[0010] The pro-C5 precursor is cleaved after amino acids 655 and
659, to yield the beta chain as an amino terminal fragment (amino
acid residues +1 to 655 of the above sequence) and the alpha chain
as a carboxyl terminal fragment (amino acid residues 660 to 1658 of
the above sequence), with four amino acids (amino acid residues
656-659 of the above sequence) deleted between the two.
[0011] C5a is cleaved from the alpha chain of C5 by either
alternative or classical C5 convertase as an amino terminal
fragment comprising the first 74 amino acids of the alpha chain
(i.e., amino acid residues 660-733 of the above sequence).
Approximately 20 percent of the 11 kDa mass of C5a is attributed to
carbohydrate. The cleavage site for convertase action is at, or
immediately adjacent to, amino acid residue 733 of the above
sequence. A compound that would bind at, or adjacent, to this
cleavage site would have the potential to block access of the C5
convertase enzymes to the cleavage site and thereby act as a
complement inhibitor.
[0012] C5 can also be activated by means other than C5 convertase
activity. Limited trypsin digestion (see, e.g., Minta and Man
(1997) J Immunol. 119:1597-1602 and Wetsel and Kolb (1982) J
Immunol. 128:2209-2216) and acid treatment (Yamamoto and Gewurz
(1978) J Immunol. 120:2008 and Damerau et al. (1989) Molec.
Immunol. 26:1133-1142) can also cleave C5 and produce active
C5b.
[0013] Cleavage of C5 releases C5a, a potent anaphylatoxin and
chemotactic factor, and leads to the formation of the lytic
terminal complement complex, C5b-9. C5a and C5b-9 also have
pleiotropic cell activating properties, by amplifying the release
of downstream inflammatory factors, such as hydrolytic enzymes,
reactive oxygen species, arachidonic acid metabolites and various
cytokines.
[0014] The first step in the formation of the terminal complement
complex involves the combination of C5b with C6, C7, and C8 to form
the C5b-8 complex at the surface of the target cell. Upon the
binding of the C5b-8 complex with several C9 molecules, the
membrane attack complex (MAC. C5b-9, terminal complement
complex--TCC) is formed. When sufficient numbers of MACs insert
into target cell membranes the openings they create (MAC pores)
mediate rapid osmotic lysis of the target cells. Lower, non-lytic
concentrations of MACs can produce other effects. In particular,
membrane insertion of small numbers of the C5b-9 complexes into
endothelial cells and platelets can cause deleterious cell
activation. In some cases activation may precede cell lysis.
[0015] As mentioned above, C3a and C5a are anaphylatoxins. These
activated complement components can trigger mast cell
degranulation, which releases histamine from basophils and mast
cells, and other mediators of inflammation, resulting in smooth
muscle contraction, increased vascular permeability, leukocyte
activation, and other inflammatory phenomena including cellular
proliferation resulting in hypercellularity. C5a also functions as
a chemotactic peptide that serves to attract pro-inflammatory
granulocytes to the site of complement activation.
[0016] C5a receptors are found on the surfaces of bronchial and
alveolar epithelial cells and bronchial smooth muscle cells. C5a
receptors have also been found on eosinophils, mast cells,
monocytes, neutrophils, and activated lymphocytes.
[0017] While a properly functioning complement system provides a
robust defense against infecting microbes, inappropriate regulation
or activation of complement has been implicated in the pathogenesis
of a variety of disorders including, e.g., rheumatoid arthritis
(RA); lupus nephritis; ischemia-reperfusion injury; atypical
hemolytic uremic syndrome (aHUS); dense deposit disease (DDD);
macular degeneration (e.g., age-related macular degeneration
(AMD)); hemolysis, elevated liver enzymes, and low platelets
(HELLP) syndrome; thrombotic thrombocytopenic purpura (TTP);
spontaneous fetal loss; Pauci-immune vasculitis; epidermolysis
bullosa; recurrent fetal loss; multiple sclerosis (MS); traumatic
brain injury; and injury resulting from myocardial infarction,
cardiopulmonary bypass and hemodialysis. (See, e.g., Holers et al.
(2008) Immmuological Reviews 223:300-316.)
SUMMARY
[0018] The present disclosure relates to compositions containing an
inhibitor of human complement (e.g., an inhibitor of complement
component C5 such as an anti-C5 antibody) and methods for using the
compositions to treat or prevent complement-associated disorders.
In some embodiments, the compositions contain an antibody, or
antigen-binding fragment thereof, that binds to a human complement
component C5 protein. In some embodiments, the compositions contain
an antibody, or antigen-binding fragment thereof, that binds to
human C5 fragment C5a or C5b. In some embodiments, the C5 inhibitor
is a small molecule or a nucleic acid such as, e.g., a siRNA or an
anti-sense RNA that binds to and promotes inactivation of C5 mRNA
in a mammal.
[0019] Complement-associated disorders include any medical disorder
in a human, the treatment of which would benefit directly or
indirectly from inhibition of the complement system. The disorders
are generally characterized by inappropriate regulation of the
complement system such as inappropriate: (i) activation of the
complement system or (ii) duration of an activated complement
system in a subject. Complement-associated disorders include,
without limitation, inflammatory and autoimmune disorders. A
complement-associated disorder can be, e.g., RA; antiphospholipid
antibody syndrome (APS); lupus nephritis; ischemia-reperfusion
injury; aHUS; typical (also referred to as diarrheal or infectious)
hemolytic uremic syndrome (tHUS); DDD; neuromyelitis optica (NMO);
multifocal motor neuropathy (MMN); MS; macular degeneration (e.g.,
AMD); HELLP syndrome; TTP; spontaneous fetal loss; Pauci-immune
vasculitis; epidermolysis bullosa; recurrent fetal loss; and
traumatic brain injury. In some embodiments, the
complement-associated disorder is a complement-associated vascular
disorder such as a cardiovascular disorder, myocarditis, a
cerebrovascular disorder, a peripheral (e.g., musculoskeletal)
vascular disorder, a renovascular disorder, a mesenteric/enteric
vascular disorder, vasculitis, Henoch-Schonlein purpura nephritis,
systemic lupus erythematosus-associated vasculitis, vasculitis
associated with rheumatoid arthritis, immune complex vasculitis,
Takayasu's disease, dilated cardiomyopathy, diabetic angiopathy,
Kawasaki's disease (arteritis), venous gas embolus (VGE), and
restenosis following stent placement, rotational atherectomy, and
percutaneous transluminal coronary angioplasty (PTCA). Additional
complement-associated disorders include, without limitation,
myasthenia gravis (MG), cold agglutinin disease (CAD),
dermatomyositis, paroxysmal cold hemoglobinuria (PCH), Graves'
disease, atherosclerosis, Alzheimer's disease, systemic
inflammatory response sepsis, septic shock, spinal cord injury,
glomerulonephritis, Hashimoto's thyroiditis, type I diabetes,
psoriasis, pemphigus, autoimmune hemolytic anemia (AIHA),
idiopathic thrombocytopenic purpura (ITP), Goodpasture syndrome,
Degos disease, and catastrophic APS (CAPS).
[0020] In one aspect, the disclosure features a method for treating
or preventing a complement-associated disorder in a human. The
method includes administering to a human in need thereof a
therapeutically effective amount of a composition comprising an
inhibitor of human complement (e.g., an inhibitor of human
complement component C5).
[0021] In another aspect, the disclosure features a method for
treating or preventing a complement-associated disorder in a human,
which method comprises administering to a human in need thereof a
composition comprising a therapeutically effective amount of an
inhibitor of human complement (e.g., an inhibitor of human
complement component C5).
[0022] In some embodiments of any of the methods described herein,
the inhibitor can inhibit the expression of a human complement
component C5 protein. The inhibitor can inhibit the protein
expression of a human complement component C5 protein or inhibit
the expression of an mRNA encoding the protein. In some embodiments
of any of the methods described herein, the inhibitor can inhibit
the cleavage of human complement component C5 into fragments C5a
and C5b.
[0023] In some embodiments of any of the methods described herein,
the inhibitor binds to, and inhibits, one or both of C5a and C5b.
The inhibitor can be, e.g., an antibody that binds to C5a or C5b.
In some embodiments, the inhibitor is an antibody that binds to
C5a, but does not bind to full-length C5. In some embodiments, the
inhibitor is an antibody that binds to C5b, but does not bind to
full-length C5. In some embodiments, the inhibitor is an antibody
that binds to a human C5a protein or a fragment thereof having an
amino acid sequence that contains, or consists of, at least four
(e.g., at least four, five, six, seven, eight, nine, 10, 11, 12,
13, 14, 15, 16, or 17 or more) consecutive amino acids depicted in
any one of SEQ ID NOs: 12-25. In some embodiments, the inhibitor is
an antibody that binds to human C5a protein having the amino acid
sequence depicted in SEQ ID NO:12. In some embodiments, the
inhibitor is an antibody that binds to a human C5b protein or
fragment thereof having an amino acid sequence that contains, or
consists of, at least four (e.g., at least four, five, six, seven,
eight, nine, 10, 11, 12, 13, 14, 15, 16, or 17 or more) consecutive
amino acids depicted in any one of SEQ ID NOs:4 or 26. In some
embodiments, the inhibitor is an antibody that binds to human C5b
protein having the amino acid sequence depicted in SEQ ID NO:4 or
26.
[0024] In some embodiments of any of the methods described herein,
the inhibitor can be selected from the group consisting of a
polypeptide, a polypeptide analog, a nucleic acid, a nucleic acid
analog, and a small molecule. The polypeptide can be, or consist
of, an antibody, or antigen-binding fragment thereof, that binds to
a human complement component C5 protein such as any of those
described herein. In some embodiments, the antibody can bind to the
alpha chain of the complement component C5 protein. In some
embodiments, the antibody can bind to the beta chain of the
complement component C5 protein. In some embodiments, the antibody
can bind to the alpha chain of human complement component C5, and
the antibody can (i) inhibit complement activation in a human body
fluid, (ii) inhibit the binding of purified human complement
component C5 to either human complement component C3b or human
complement component C4b, and/or (iii) not bind to the human
complement activation product free C5a (or a combination of any of
the foregoing properties). The antibody can bind to the human
complement component C5 protein having, or consisting of, the amino
acid sequence depicted in any one of SEQ ID NOs:1-11. The antibody
can bind to an isolated oligopeptide comprising an amino acid
sequence corresponding to amino acid position 8 through amino acid
position 12 of SEQ ID NO:5. In some embodiments, the antibody can
be a monoclonal antibody, a single-chain antibody, a humanized
antibody, a fully human antibody, a polyclonal antibody, a
recombinant antibody, a diabody, a chimerized or chimeric antibody,
a deimmunized human antibody, a fully human antibody, a single
chain antibody, an Fv fragment, an Fd fragment, an Fab fragment, an
Fab' fragment, or an F(ab').sub.2 fragment. In some embodiments,
the antibody can be eculizumab or pexelizumab.
[0025] In some embodiments of any of the methods described herein,
the composition can be intravenously administered to the human.
[0026] In some embodiments of any of the methods described herein,
the complement-associated disorder is an alternative complement
pathway-associated disorder. In some embodiments of any of the
methods described herein, the complement-associated disorder is a
classical complement pathway-associated disorder. In some
embodiments, the complement-associated disorder is selected from
the group consisting of rheumatoid arthritis, ischemia-reperfusion
injury, atypical hemolytic uremic syndrome, thrombotic
thrombocytopenic purpura, dense deposit disease, age-related
macular degeneration, spontaneous fetal loss, Pauci-immune
vasculitis, epidermolysis bullosa, recurrent fetal loss, multiple
sclerosis, HELLP, pre-eclampsia, traumatic brain injury,
Alzheimer's disease, myasthenia gravis, cold agglutinin disease,
dermatomyositis, Graves' disease, Hashimoto's thyroiditis, type I
diabetes, psoriasis, pemphigus, autoimmune hemolytic anemia,
idiopathic thrombocytopenic purpura. Goodpasture syndrome,
antiphospholipid syndrome, catastrophic antiphospholipid syndrome,
neuromyelitis optica (NMO), multifocal motor neuropathy (MMN),
Degos disease, and any other complement-associated disorder
described herein.
[0027] In some embodiments, any of the methods described herein can
further include the step of identifying the human as having,
suspected of having, or at risk for developing, a
complement-associated disorder. In some embodiments, any of the
methods described herein can also include, after the administering,
monitoring the human for an improvement in one or more symptoms of
the complement-associated disorder.
[0028] In embodiments of any of the methods described herein where
the complement-associated disorder is aHUS, the aHUS can be
genetic, acquired, or idiopathic form. In some embodiments, the
aHUS can be complement factor H (CFH)-associated aHUS (e.g., due to
mutations in CFH or the presence of antibodies in the subject that
bind to CFH), membrane cofactor protein (MCP)-associated aHUS,
complement factor I (CFI)-associated aHUS, C4b-binding protein
(C4BP)-associated aHUS, a von Willibrand Factor (vWF)-associated
disorder, complement factor B-(CFB)-associated aHUS, or a disorder
of the alternative pathway that results in low C3 levels as a
result of increased C3 consumption.
[0029] In some embodiments, any of the methods described herein can
further include identifying the subject as one having, suspected of
having, or at risk for developing, aHUS.
[0030] In some embodiments, any of the methods described herein can
include, after the administering, monitoring the subject for an
improvement in one or more symptoms of aHUS.
[0031] In some embodiments of any of the methods described herein,
the composition can be administered to the subject prior to,
during, or following a plasma therapy (e.g., plasma exchange or
plasma infusion). In some embodiments, administration of the C5
inhibitor to the subject can alleviate the need for plasma therapy
by a patient. For example, in some embodiments, administration
(e.g., chronic administration) of the C5 inhibitor to the subject
can alleviate or substantially reduce the need for plasma therapy
by a patient for at least 2 months (e.g., 3 months, 4 months, 5
months, 6 months, 7 months, 8 months, 9 months, 10 months, 11
months, or 12 months or 1, 2, 3, 4, 5, or 6 years or more). In some
embodiments, any of the methods described herein can include
administering to the subject one or more additional active agents
useful for treating typical HUS or aHUS. The one or more additional
active agents can be, e.g., selected from the group consisting of
anti-hypertensives, anti-platelet agents, prostacyclin,
fibrinolytic agents, and anti-oxidants.
[0032] In some embodiments, the human is an infant. The infant can
be, e.g., 0.5 (e.g., 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6,
6.5, 7, 7.5, 8, 8.5, 9, or 9.5) years old. The infant can be less
than 10 (e.g., less than 9.5, 9, 8.5, 8, 7.5, 7, 6.5, 6, 5.5, 5,
4.5, 4, 3.5, 3, 2.5, 2, 1.5, 1, or less than 1) year(s) old.
[0033] In embodiments of any of the methods described herein where
the complement-associated disorder is typical HUS, the typical HUS
can be associated with an E. coli infection in or on the human. The
E. coli infection can be, e.g., an E. coli O157 (e.g., O157:H7),
O26, O103, O111, or O145 infection. In some embodiments of any of
the methods described herein, the typical hemolytic uremic syndrome
can be associated with a Shigella dysenteriae infection in or on
the human. The Shigella dysenteriae infection can be a Shigella
dysenteriae type 1 infection.
[0034] In some embodiments, any of the methods described herein can
further include identifying the human as one having, suspected of
having, or at risk for developing, typical hemolytic uremic
syndrome.
[0035] In some embodiments, any of the methods described herein can
include, after the administering, monitoring the human for an
improvement in one or more symptoms of typical hemolytic uremic
syndrome.
[0036] In embodiments of any of the methods described herein where
the complement-associated disorder is CAPS, the CAPS can be
associated with a precipitating condition. Precipitating conditions
can include, e.g., a cancer, transplantation, an infection,
surgery, primary antiphospholipid syndrome, or an autoimmune
disorder such as rheumatoid arthritis or systemic lupus
erythematosus. Accordingly, in some embodiments, the CAPS can be
associated with a cancer such as, but not limited to, gastric
cancer, ovarian cancer, lymphoma, leukemia, endometrial cancer,
adenocarcinoma, lung cancer, or any other cancers known in the art
to precipitate or be associated with CAPS. In some embodiments, the
CAPS can be idiopathic.
[0037] In some embodiments, any of the methods described herein can
also include identifying the human as one having, suspected of
having, or at risk for developing, CAPS. In some embodiments, any
of the methods described herein can include, after the
administering, monitoring the human for an improvement in one or
more symptoms of CAPS.
[0038] In some embodiments of any of the methods described herein,
the composition can be administered to the human prior to, during,
or following a plasma exchange, plasmapheresis, IVIG, or any other
additional therapy for treating CAPS.
[0039] In some embodiments, any of the methods described herein can
also include administering to the human one or more additional
active agents useful for treating CAPS. The one or more additional
active agents can be selected from the group consisting of
anti-hypertensives, anti-cytokine agents, steroids,
anti-coagulants, or fibrinolytic agents.
[0040] In embodiments of any of the methods described herein where
the complement-associated disorder is TTP, the TTP can be
inherited. For example, a human can carry one or more (e.g., two,
three, four, or five or more) mutations in the ADAMTS13 gene. In
some embodiments of any of the methods described herein, the TTP
can be an acquired form. For example, in some embodiments, the
human can produce antibodies that bind to, and inhibit, the
ADAMTS13 metalloproteinase. In some embodiments of any of the
methods described herein, the TTP can be a recurrent form. For
example, the human can be one who has had TTP. In some embodiments
of any of the methods described herein, the TTP (or recurrent TTP)
is associated with a precipitating condition such as, but not
limited to, a cancer, pregnancy, bacterial or viral infection,
surgery, or any other TTP-associated condition known in the art or
described herein. In some embodiments of any of the methods
described herein, the TTP (or recurrent TTP) is associated with the
use of a therapeutic agent associated with TTP. For example, the
TTP can be associated with the use of, e.g., a platelet aggregation
inhibitor such as ticlopidine or clopidogrel or an
immunosuppressant (e.g., cyclosporine, mitomycin C, FK506, or
interferon-alpha).
[0041] In some embodiments, any of the methods described herein can
include identifying the human as one having, suspected of having,
or at risk for developing, TTP. In some embodiments, any of the
methods described herein can include, after the administering,
monitoring the human for an improvement in one or more symptoms of
TTP.
[0042] In some embodiments of any of the methods described herein,
the composition can be administered to the human prior to, during,
or following a plasma exchange, plasma infusion, plasmapheresis, or
a splenectomy. In some embodiments, any of the methods described
herein can include administering to the human one or more
additional active agents useful for treating or preventing TTP. The
one or more additional active agents can be selected from the group
consisting of anti-hypertensives, steroids, anti-coagulants, or
fibrinolytic agents.
[0043] In embodiments of any of the methods described herein where
the complement-associated disorder is DDD, the DDD can be an
inherited form of the disorder. For example, a human can have a
DDD-associated mutation in the complement factor H gene, the
complement factor H-related 5 gene, or the complement component C3
gene.
[0044] In some embodiments, any of the methods described herein can
include identifying the human as one having, suspected of having,
or at risk for developing, DDD. In some embodiments, any of the
methods described herein can include, after the administering,
monitoring the human for an improvement in one or more symptoms of
DDD.
[0045] In some embodiments of any of the methods described herein,
the composition can be administered to the human prior to, during,
or following a plasma exchange, plasma replacement, plasmapheresis,
or intravenous gamma globulin therapy. In some embodiments, any of
the methods described herein can include administering to the human
one or more additional active agents useful for treating DDD. The
one or more additional active agents can be selected from the group
consisting of anti-hypertensives, corticosteroids, anti-coagulants,
or fibrinolytic agents.
[0046] In embodiments of any of the methods described herein where
the complement-associated disorder is MG, the human can be one
expressing an MG-associated autoantibody such as, but not limited
to, an MG-associated anti-AChR antibody, an MG-associated anti-MuSK
antibody, or an MG-associated anti-striational protein antibody.
The MG can be ocular MG and/or a drug-induced form of MG such as
D-penicillamine-induced MG. In some embodiments, the human can be
in, or be at risk for developing, myasthenic crisis. In some
embodiments, the human can be a neonate having neonatal MG, wherein
a mother with MG passes MG-associated antibodies through the
placenta to an infant.
[0047] In some embodiments, any of the methods described herein can
further include identifying the human as one having, suspected of
having, or at risk for developing, MG. In some embodiments, any of
the methods described herein can further include, after the
administering, monitoring the human for an improvement in one or
more symptoms of MG. In some embodiments of any of the methods
described herein, the composition can be administered to the human
prior to, during, or following a plasma exchange, plasmapheresis.
IVIG, or immunoadsorption therapy.
[0048] In some embodiments, any of the methods described herein can
include administering to the human one or more additional active
agents useful for treating or preventing MG. The one or more
additional active agents can be, e.g., acetylcholinesterase
inhibitors, immunosuppressive agents, or any other additional
active agents useful for treating MG that are known in the art or
described herein.
[0049] In embodiments of any of the methods described herein where
the complement-associated disorder is paroxysmal cold
hemoglobinuria (PCH), the PCH can be associated with an infection
(e.g., a viral or bacterial infection) or a neoplasm. For example,
the PCH can be associated with a Treponema palladium infection, an
influenza virus infection, a varicella-zoster virus infection, a
cytomegalovirus (CMV) infection, an Epstein-Barr virus (EBV)
infection, an adenovirus infection, a parvovirus B19 infection, a
Coxsackie A9 infection, a Haemophilus influenza infection, a
Mycoplasma pneumoniae infection, or a Klebsiella pneumoniae
infection. In some embodiments, the PCH can be associated with
non-Hodgkin's lymphoma. In some embodiments, the PCH can be
associated with an immunization (e.g., a measles immunization). In
some embodiments of any of the methods described herein, the PCH
can be acute or recurrent.
[0050] In some embodiments, any of the methods described herein can
include identifying the human as one having, suspected of having,
or at risk for developing, PCH. In some embodiments, any of the
methods described herein can include, after the administering,
monitoring the human for an improvement in one or more symptoms of
PCH.
[0051] In some embodiments of any of the methods described herein,
the composition can be administered to the human prior to, during,
or following a plasma exchange, plasma infusion, IVIG therapy, red
cell transfusion, or plasmapheresis. In some embodiments, any of
the methods described herein can include administering to the human
one or more additional active agents useful for treating or
preventing PCH. The one or more additional active agents can be
selected from the group consisting of anti-hypertensives, steroids,
immunosuppressives (e.g., rituximab), antibiotics, anti-viral
agents, and chemotherapeutic agents.
[0052] In embodiments of any of the methods described herein where
the complement-associated disorder is CAD, the CAD can be
associated with an infection (e.g., a viral or bacterial infection)
or a neoplasm. For example, the CAD can be associated with an HIV
infection, a cytomegalovirus (CMV) infection, an Epstein-Barr virus
(EBV) infection, or a Mycoplasma pneumoniae infection. In some
embodiments, the CAD can be associated with non-Hodgkin's lymphoma.
In some embodiments of any of the methods described herein, the CAD
can be primary or secondary.
[0053] In some embodiments, any of the methods described herein can
include identifying the human as one having, suspected of having,
or at risk for developing, CAD. In some embodiments, any of the
methods described herein can include, after the administering,
monitoring the human for an improvement in one or more symptoms of
CAD.
[0054] In some embodiments of any of the methods described herein,
the composition can be administered to the human prior to, during,
or following a plasma exchange, plasma replacement, IVIG therapy,
or plasmapheresis. In some embodiments, any of the methods
described herein can include administering to the human one or more
additional active agents useful for treating or preventing CAD. The
one or more additional active agents can be selected from the group
consisting of anti-hypertensives, steroids, immunosuppressives
(e.g., rituximab), antibiotics, anti-viral agents, and
chemotherapeutic agents.
[0055] In embodiments of any of the methods described herein where
the complement-associated disorder is HELLP syndrome, the affected
woman can be pregnant or can be a woman who has recently been
pregnant. For example, the woman can be one who has given birth
less than 14 days (e.g., less than 13 days, 12 days, 11 days, 10
days, nine days, eight days, seven days, six days, five days, four
days, three days, two days, 24 hours, 18 hours, 12 hours, 6 hours,
or less than 4, 3, 2, or 1 hours) prior to administration. In some
embodiments, the woman has been pregnant more than one time. In
some embodiments, the woman can be one who has developed
preeclampsia or HELLP syndrome during at least one prior
pregnancy.
[0056] In embodiments where the complement-associated disorder is
HELLP syndrome, the methods described herein can further include
the step of identifying the woman as one having, suspected of
having, or at risk for developing, HELLP syndrome. In some
embodiments, any of the methods described herein can further
include the step of, after the administering, monitoring the woman
for an improvement in one or more symptoms of HELLP syndrome.
[0057] In some embodiments of any of the methods described herein,
the composition can be administered to the woman prior to, during,
or following a plasma exchange, plasmapheresis, platelet
transfusion, or red blood cell transfusion.
[0058] In some embodiments, any of the methods described herein can
include the step of administering to the woman at least one or more
additional active agents useful for treating or preventing HELLP
syndrome in a woman. The one or more additional active agents can
be selected from the group consisting of an anti-hypertensive, a
steroid, an anti-seizure agent, and an anti-thrombotic agent.
[0059] In yet another aspect, the disclosure features an article of
manufacture, which includes (or consists of) a container with a
label and a composition containing an inhibitor of human complement
(e.g., an inhibitor of human complement component C5). The label
indicates that the composition is to be administered to a human
having, suspected of having, or at risk for developing, a
complement-associated disorder such as any of the
complement-associated disorders described herein. The inhibitor can
be, e.g., an antibody or antigen-binding fragment thereof that
binds to complement component C5 or a fragment thereof such as C5a
or C5b. In some embodiments, the article of manufacture contains
one or more additional active agents that are useful for treating
or preventing a complement-associated disorder (e.g., ameliorating
one or more symptoms of the disorder).
[0060] The disclosure is also based, in part, on the discovery by
the inventors that upon treatment with the C5 inhibitor eculizumab,
a patient with the complement-associated disorder aHUS and
thrombotic microangiopathy (TMA) in the kidney experienced a
complete resolution of the TMA in the kidney with no further
development of TMA. Accordingly, in another aspect, the disclosure
features a method for treating thrombotic microangiopathy (TMA), or
reducing the occurrence or severity of TMA, in a patient who has,
is suspected of having, or at risk of developing TMA. The method
includes administering to the patient (being in need thereof) an
inhibitor of complement such as an inhibitor of complement
component C5 to thereby treat TMA in the patient. The inhibitor can
be, e.g., any of the C5 inhibitors described herein, e.g.,
eculizumab. Administration of the C5 inhibitor can reduce the
occurrence or severity of TMA in the brain and/or kidney of the
patient. In some embodiments, administration of the C5 inhibitor
treats or promotes the resolution of pre-existing TMA in the
patient, e.g., a pre-existing TMA in the brain or kidney of the
patient.
[0061] In some embodiments, the patient has a complement
associated-disorder such as any of those described herein, e.g.,
membranoproliferative glomerulonephritis, Degos disease, atypical
hemolytic uremic syndrome, antibody-mediated rejection, HELLP
syndrome, or catastrophic antiphospholipid syndrome.
[0062] The inventors have also discovered that administration of
eculizumab to patients with, e.g., aHUS or CAPS results in an
unexpectedly rapid amelioration of one or more symptoms of the
diseases. For example, the inventors have discovered that
hypertension, reduced urine output, and low platelet levels are
ameliorated in eculizumab-treated aHUS patients in less than one
month (e.g., less than two weeks) from initiating chronic treatment
with eculizumab. In another example, the inventors discovered that
the proteinuria in a patient with membranoproliferative
glomerulonephritis was ameliorated within a month following
initiation of chronic treatment with eculizumab. Accordingly, in
yet another aspect, the disclosure features a method for
ameliorating one or more symptoms associated with a
complement-associated disorder such as any of the
complement-associated disorders described herein with the exception
of paroxysmal nocturnal hemoglobinuria. The method includes
administering to a patient in need thereof an inhibitor of
complement (e.g., an inhibitor of complement component C5) in an
amount effective to ameliorate one or more symptoms associated a
complement-associated disorder, wherein the symptoms are
ameliorated within less than two months (e.g., less than 7, 6, 5,
4, 3, or 2 weeks, less than 20, 19, 18, 17, 16, 15, 14, 13, 12, 11,
10, 9, 8, 7, 6, 5, 4, 3, 2, or 1 day(s); or less than 12, 11, 10,
9, 8, 7, 6 or even less than 5 hours) after administering the
inhibitor. Symptoms of complement-associated disorders are well
known in the art of medicine and described herein. The complement
inhibitor can be any of the C5 inhibitors described herein, e.g.,
eculizumab. Exemplary symptoms that may be ameliorated by the C5
inhibitor in less than 2 months include, e.g., proteinuria,
hypertension, reduced platelet counts, and reduced urine output
from the kidney. In some embodiments, at least one of the symptoms
is ameliorated to within 40 (e.g., 39, 38, 37, 36, 35, 34, 33, 32,
31, 30, 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15,
14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, or even 1) % of its
normal level or value. For example, in some embodiments,
administration of the C5 inhibitor eculizumab to a hypertensive
patient with aHUS can ameliorate the patient's hypertension to
within 40% of the normal blood pressure (diastolic and/or systolic)
for the patient. In some embodiments, administration of the C5
inhibitor can completely ameliorate one or more symptoms of the
complement-associated disorder in the subject. In some embodiments,
the patient has had a kidney transplant, e.g., an aHUS patient who
has recently undergone a kidney transplant. The complement
associated-disorder can be any of those described herein, e.g.,
membranoproliferative glomerulonephritis, Degos disease, atypical
hemolytic uremic syndrome, antibody-mediated rejection, HELLP
syndrome, and catastrophic antiphospholipid syndrome.
[0063] Many of the complement-associated disorders described herein
are characterized by episodic or sporadic symptom presentation and
historically have only been treated when symptoms manifest.
However, the inventors have discovered that an underlying
complement-associated disorder remains present even when the
patients are asymptomatic. The inventors have also discovered that
recurrences or relapses of the disorders can be prevented or at
least minimized by chronic treatment using a complement-mediated
inhibitor. Such chronic administration of the inhibitor is useful
to prevent or minimize the often irreversible damage (e.g., loss of
an organ such as a kidney) inflicted upon patients with severe
complement-related disorders (e.g., aHUS or CAPS) when the relapses
occur. Accordingly, it is of the utmost importance to administer a
complement inhibitor to the patient in an amount and with a
frequency sufficient to continually maintain a concentration of the
inhibitor that is high enough to prevent or substantially inhibit
systemic complement activity in the patients.
[0064] Thus, in another aspect, the disclosure features a method
for treating a complement-associated disorder, which method
includes chronically administering to a patient in need thereof a
complement inhibitor (e.g., a C5 inhibitor such as an anti-C5
antibody) in an amount and with a frequency that are effective to
maintain systemic complement inhibition in the patients with the
proviso that the complement-associated disorder is not paroxysmal
nocturnal hemoglobinuria.
[0065] As used herein, "chronically administered," "chronic
treatment." "treating chronically," or similar grammatical
variations thereof refer to a treatment regimen that is employed to
maintain a certain threshold concentration of a therapeutic agent
in the blood of a patient in order to completely or substantially
suppress systemic complement activity in the patient over a
prolonged period of time. Accordingly, a patient chronically
treated with a complement inhibitor can be treated for a period of
time that is greater than or equal to 2 weeks (e.g., 3, 4, 5, 6, 7,
8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24,
25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41,
42, 43, 44, 45, 46, 47, 48, 49, 50, 51, or 52 weeks; 1, 2, 3, 4, 5,
6, 7, 8, 9, 10, 11, or 12 months; or 1, 1.5, 2, 2.5, 3, 3.5, 4,
4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 10.5, or 12 years
or for the remainder of the patient's life) with the inhibitor in
an amount and with a dosing frequency that are sufficient to
maintain a concentration of the inhibitor in the patient's blood
that inhibits or substantially inhibits systemic complement
activity in the patient. In some embodiments, the complement
inhibitor can be chronically administered to a patient in need
thereof in an amount and with a frequency that are effective to
maintain serum hemolytic activity at less than or equal to 20
(e.g., 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, or even
below 5)% and to maintain serum hemolytic activity at less than or
equal to 20%. See, e.g., Hill et al. (2005) Blood 106(7):2559. In
some embodiments, the complement inhibitor can be administered to a
patient in an amount and with a frequency that are effective to
maintain serum lactate dehydrogenase (LDH) levels at within at
least 20 (e.g., 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6,
or even below 5) % of the normal range for LDH. See Hill et al.
(2005) supra. In some embodiments, the complement inhibitor is
administered to the patient in an amount and with a frequency that
are effective to maintain a serum LDH level less than 550 (e.g.,
less than 540, 530, 520, 510, 500, 490, 480, 470, 460, 450, 430,
420, 410, 400, 390, 380, 370, 360, 350, 340, 330, 320, 310, 300,
290, 280, or less than 270) IU/L. To maintain systemic complement
inhibition in a patient, the complement inhibitor can be
chronically administered to the patient, e.g., once a week, once
every two weeks, twice a week, once a day, once a month, or once
every three weeks. In some embodiments of any of the methods
described herein, a C5 inhibitor (e.g., an anti-C5 antibody) can be
administered to a patient in an amount and with a frequency of
administration effective to maintain a concentration of at least
0.7 (e.g., at least 0.8, 0.9, one, two, three, four, five, six,
seven, eight, nine, or 10 or more) divalent C5 inhibitor
molecule(s) (e.g., a whole anti-C5 antibody such as eculizumab) per
every C5 molecule in the patient's blood. "Divalent" or "bivalent,"
with respect to a C5 inhibitor, refers to a C5 inhibitor that
contains at least two binding sites for a C5 molecule. Where the C5
inhibitor is monovalent (e.g., a single chain anti-C5 antibody or a
Fab that binds to C5), the inhibitor can be administered to the
patient in an amount and with a frequency that are effective to
maintain a concentration of at least 1.5 (e.g., at least 2, 2.5, 3,
3.5, 4, 4.5, or 5 or more) of the monovalent C5 inhibitors per
every C5 molecule in the blood. In some embodiments, the monovalent
C5 inhibitor can be administered to the patient in an amount and
with a frequency that are effective to maintain a ratio of
monovalent C5 inhibitor to C5 of at least 2:1 (e.g., at least 3:1,
at least 4:1, at least 5:1, or at least 6:1 or more). In some
embodiments of any of the methods described herein, a whole
(bivalent) anti-C5 antibody is administered to the patient in an
amount and with a frequency that are effective to maintain a
concentration of at least 40 (e.g., 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, 75, 80, 85, 90, 95, 100, 110, or 120 or more)
.mu.g of the antibody per milliliter of the patient's blood. In
preferred embodiments, a whole anti-C5 antibody (e.g., eculizumab)
is administered in an amount and with a frequency to maintain the
antibody at a concentration of at least 50 .mu.g per milliliter of
the patient's blood. In preferred embodiments, a whole anti-C5
antibody (e.g., eculizumab) is administered in an amount and with a
frequency to maintain the antibody at a concentration of at least
100 .mu.g per milliliter of the patient's blood. In some
embodiments of any of the methods described herein, a monovalent
anti-C5 antibody (e.g., a single chain antibody or an Fab fragment)
can be administered to the patient in an amount and with a
frequency that are effective to maintain a concentration of at
least 80 (e.g., 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93,
94, 95, 96, 97, 98, 99, 100, 110, 115, 120, 125, 130, 135, 140,
145, 150, 155, 160, 165, or a 170 or more) .mu.g of the antibody
per milliliter of the patient's blood. Exemplary chronic dosing
strategies are described herein.
[0066] In another aspect, the disclosure features a method for
treating a complement-associated disorder, which method includes
chronically administering to a patient in need thereof an anti-C5
antibody in an amount and with a frequency that are effective to
maintain systemic complement inhibition in the patients. In some
embodiments, the anti-C5 antibody can be chronically administered
to a patient in need thereof in an amount and with a frequency that
are effective to maintain serum hemolytic activity at less than or
equal to 20 (e.g., 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7,
6, or even below 5) % and to maintain the serum hemolytic activity
at less than or equal to 20%. See, e.g., Hill et al. (2005) Blood
106(7):2559. In some embodiments, the anti-C5 antibody can be
administered to a patient in an amount and with a frequency that
are effective to maintain serum lactate dehydrogenase (LDH) levels
at within: at least 20 (e.g., 19, 18, 17, 16, 15, 14, 13, 12, 11,
10, 9, 8, 7, 6, or even below 5) % of the normal range for LDH; or
less than or equal to 550 (e.g., less than or equal to 550, 540,
530, 520, 510, 500, 490, 480, 470, 460, 450, 430, 420, 410, 400,
390, 380, 370, 360, 350, 340, 330, 320, 310, 300, 290, 280, or less
than 270) IU/L. See, e.g., Hill et al. (2005) supra. In some
embodiments, the anti-C5 antibody is administered to the patient in
an amount and with a frequency to maintain a concentration of at
least 0.7 (e.g., at least 0.8, 0.9, 1, 2, 3, or 4 or more) whole
(bivalent) anti-C5 antibody molecule(s) per every C5 molecule in
the patient's blood. In some embodiments, the anti-C5 antibody can
be administered to the patient in an amount and with a frequency
that are effective to maintain a ratio of whole (bivalent) anti-C5
antibody to C5 in the blood of at least 1:1 (e.g., at least 3:2,
2:1, 5:2, or 3:1). Where the anti-C5 antibody is monovalent, the
anti-C5 antibody can be administered to the patient in an amount
and with a frequency that are effective to maintain a concentration
of at least 2 of the monovalent anti-C5 antibodies per every C5
molecule in the blood. In some embodiments, the monovalent anti-C5
antibody can be administered to the patient in an amount and with a
frequency that are effective to maintain a ratio of monovalent
anti-C5 antibody to C5 of at least 2:1 (e.g., at least 3:1, at
least 4:1, at least 5:1, or 6:1 or more). The anti-C5 antibody can
be, e.g., eculizumab. The patient can have, be suspected of having,
or be at risk for developing a complement-associated disorder with
the proviso that the disorder is not paroxysmal nocturnal
hemoglobinuria. For example, the complement-associated disorder can
be one selected from the group consisting of membranoproliferative
glomerulonephritis, Degos disease, atypical hemolytic uremic
syndrome, antibody-mediated rejection, HELLP syndrome, and
catastrophic antiphospholipid syndrome.
[0067] In some embodiments of any of the methods described herein,
an anti-C5 antibody can be administered chronically to a patient
based on his or her weight. In some embodiments of any of the
methods described herein, an anti-C5 antibody (e.g., eculizumab)
can be administered chronically to a patient based on his or her
weight and under the dosing schedule set forth in Table 1.
TABLE-US-00001 TABLE 1 Exemplary Chronic Dosing Schedules for a
Whole Anti-C5 Antibody (e.g., eculizumab) by Patient Weight
Induction/Loading Maintenance Dosing Patient Weight Dosing (A) (B)
Adults of any At least 800 (e.g., at At least 800 Following the (A)
weight or any least 810, 820, 830, (e.g., at least dose, at least
800 patient with a 840, 850, 860, 870, 880, 810, 820, 830, (e.g.,
at least 810, body weight that 890, 900, 910, 920, 930, 840, 850,
860, 820, 830, 840, 850, is greater than or 940, 950, 960, 970,
980, 870, 880, 890, 860, 870, 880, 890, equal to 40 kg 990, 1000,
1100, or 900, 910, 920, 900, 910, 920, 930, 1200 or more) mg once
930, 940, 950, 940, 950, 960, 970, a week for four weeks 960, 970,
980, 980, 990, 1000, 990, 1000, 1050, 1100, 1150, 1050, 1100, 1200,
1250, 1300, 1150, 1200, 1350, or 1400 or 1250, 1300, more) mg once
1350, or 1400 every two weeks or more) mg thereafter* on week five
Body weight that At least 500 (e.g., at At least 800 Following the
(A) is less than 40 kg, least 510, 520, 530, (e.g., at least dose,
at least 800 hut greater than or 540, 550, 560, 570, 580, 810, 820,
830, (e.g., at least 810, equal to 30 kg 590, 600, 610, 620, 630,
840, 850, 860, 820, 830, 840, 850, 640, 650, 660, 670, 680, 870,
880, 890, 860, 870, 880, 890, 690, 700, 710, 720, 730, 900, 910,
920, 900, 910, 920, 930, 740, 750, 760, 770, 780, 930, 940, 950,
940, 950, 960, 970, 790, 800, or 850 or 960, 970, 980, 980, 990,
1000, more) mg once a week 990, 1000, 1050, 1100, 1150, for two
weeks 1050, 1100, 1200, 1250, 1300, 1150, 1200, 1350, or 1400 or
1250, 1300, more) mg once 1350, or 1400 every two weeks or more) mg
thereafter* on week three Body weight that At least 500 (e.g., at
At least 500 Following the (A) is less than 30 kg, least 510, 520,
530, (e.g., at least dose, at least 500 but greater than or 540,
550, 560, 570, 580, 510, 520, 530, (e.g., at least 510, equal to 20
kg 590, 600, 610, 620, 630, 540, 550, 560, 520, 530, 540, 550, 640,
650, 660, 670, 680, 570, 580, 590, 560, 570. 580. 590, 690, 700,
710, 720, 730, 600, 610, 620, 600, 610, 620, 630, 740, 750, 760,
770, 780, 630, 640, 650, 640, 650, 660, 670, 790, 800, or 850 or
660, 670, 680, 680, 690, 700, 710, more) mg once a week 690, 700,
710, 720, 730, 740, 750, for two weeks 720, 730, 740, 760, 770,
780, 790, 750, 760, 770, 800, or 850 or more) 780, 790, 800, mg
once every two or 850 or weeks thereafter* more) mg on week three
Body weight that At least 500 (e.g., at At least 200 Following the
(A) is less than 20 kg, least 510, 520, 530, (e.g., at least dose,
at least 200 but greater than or 540, 550, 560, 570, 580, 210, 220,
230, (e.g., at least 210, equal to 10 kg 590, 600, 610, 620, 630,
240, 250, 260, 220, 230, 240, 250, 640, 650, 660, 670, 680, 270,
280, 290, 260, 270, 280, 290, 690, 700, 710, 720, 730, 300, 310,
320, 300, 310, 320, 330, 740, 750, 760, 770, 780, 330, 340, 350,
340, 350, 360, 370, 790, 800, or 850 or 360, 370, 380, 380, 390,
400, 410, more) mg once a week 390, 400, 410, 420, 430, 440, 450,
for one week 420, 430, 440, 460, 470, 480, 490, 450, 460, 470, 500,
or 550 or more) 480, 490, 500, mg once every two or 550 or weeks
thereafter* more) mg on week two Body weight that At least 200
(e.g., at At least 200 Following the (A) is less than 10 kg, least
210, 220, 230, (e.g., at least dose, at least 200 but greater than
or 240, 250, 260, 270, 280, 210, 220, 230, (e.g., at least 210,
equal to 5 kg 290, 300, 310, 320, 330, 240, 250, 260, 220, 230,
240, 250, 340, 350, 360, 370, 380, 270, 280, 290, 260, 270, 280,
290, 390, 400, 410, 420, 430, 300, 310, 320, 300, 310, 320, 330,
440, 450, 460, 470, 480 330, 340, 350, 340, 350, 360, 370, 490,
500, or 550 or 360, 370, 380, 380, 390, 400, 410, more) mg once a
week 390, 400, 410, 420, 430, 440, 450, for one week 420, 430, 440,
460, 470, 480, 490, 450, 460, 470, 500, or 550 or more) 480, 490,
500, mg once every three or 550 or weeks thereafter* more) rag on
week two *In accordance with the present disclosure, the (B)
maintenance dosing schedule can be maintained for the duration of
the treatment regimen, e.g., at least one (e.g., at least two,
three, four, five, six, seven, eight, nine, 10, 11, 12, 13, 14, 15,
16, 17, 18, 19, 20, 22, 24, 36, or 48 or more) month(s); at least
one (e.g., at least two, three, four, five, six, seven, eight,
nine, 10, 11, 12, 13, 14, or 15 or more) years; or for the
remainder of the patient's life.
[0068] In preferred embodiments, an anti-C5 antibody (e.g.,
eculizumab) can be administered to a patient based on his or her
weight under the dosing schedules set forth in Table 2.
TABLE-US-00002 TABLE 2 Exemplary Chronic Dosing Schedules for a
Whole Anit-C5 Antibody (e.g., eculizumab) by Patient Weight
Induction/Loading Maintenance Dosing Patient Weight Dosing (A) (B)
Adults of any At least 900 (e.g., at At least 1200 Following the
(A) weight or any least 910, 920, 930, (e.g., at least dose, at
least 1200 patient with a 940, 950, 960, 970, 980, 1225, 1250,
(e.g.. at least 1225, body weight that 990, 1000, 1100, or 1300,
1350, or 1250, 1300, 1350, or is greater than or 1200 or more) mg
once 1400 or more) 1400 or more) mg equal to 40 kg a week for four
weeks mg on week once every two five weeks thereafter* Body weight
that At least 600 (e.g., at At least 900 Following the (A) is less
than 40 kg, least 610, 620, 630, (e.g., at least dose, at least 900
but greater than or 640, 650, 660, 670, 680, 910, 920, 930, (e.g..
at least 910, equal to 30 kg 690, 700, 710, 720, 730, 940, 950,
960, 920, 930, 940, 950, 740, 750, 760, 770, 780, 970, 980, 990,
960, 970, 980, 990, 790, 800, or 850 or 1000, 1050, 1000, 1050,
1100, more) mg once a week 1100, 1150, or 1150, or 1200 or for two
weeks 1200 or more) more) mg once mg on week every two weeks three
thereafter* Body weight that At least 600 (e.g., at At least 600
Following the (A) is less than 30 kg, least 610, 620, 630, (e.g.,
at least dose, at least 600 but greater than or 640, 650, 660, 670.
680, 610, 620, 630, (e.g., at least 610, equal to 20 kg 690, 700,
710, 720, 730, 640, 650, 660, 620, 630, 640, 650, 740, 750, 760,
770, 780, 670, 680, 690, 660, 670, 680, 690, 790, 800, or 850 or
700, 710, 720, 700, 710, 720, 730, more) mg once a week 730, 740,
750, 740, 750, 760, 770, for two weeks 760, 770, 780, 780, 790,
800, or 790, 800, or 850 or more) mg 850 or more) once every two mg
on week weeks thereafter* three Body weight that At least 600
(e.g., at At least 300 Following the (A) is less than 20 kg, least
610, 620, 630, (e.g., at least dose, at least 300 but greater than
or 640, 650, 660, 670, 680, 310, 320, 330, (e.g., at least 310,
equal to 10 kg 690, 700, 710, 720, 730, 340, 350, 360, 320, 330,
340, 350, 740, 750, 760, 770, 780, 370, 380, 390, 360, 370, 380,
390, 790, 800, or 850 or 400, 410, 420, 400, 410, 420, 430, more)
mg once a week 430, 440, 450, 440, 450, 460, 470, for one week 460,
470, 480, 480, 490, 500, or 490, 500, or 550 or more) mg 550 or
more) once every two mg on week weeks thereafter* two Body weight
that At least 300 (e.g., at At least 300 Following the (A) is less
than 10 kg, least 310, 320, 330, (e.g., at least dose, at least 300
but greater than or 340, 350, 360, 370, 380, 310, 320, 330, (e.g.,
at least 310, equal to 5 kg 390, 400, 410, 420, 430, 340, 350, 360,
320, 330, 340, 350, 440, 450, 460, 470, 480, 370, 380, 390, 360,
370, 380, 390, 490, 500, or 550 or 400, 410, 420, 400, 410, 420,
430, more) mg once a week 430, 440, 450, 440, 450, 460, 470, for
one week 460, 470, 480, 480, 490, 500, or 490, 500, or 550 or more)
mg 550 or more) once every three mg on week weeks thereafter* two
*In accordance with the present disclosure, the (B) maintenance
dosing schedule can be maintained for the duration of the treatment
regimen, e.g., at least one (e.g., at least two, three, four, five,
six, seven, eight, nine, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19,
20, 22, 24, 36, or 48 or more) month(s); at least one (e.g., at
least two, three, four, five, six, seven, eight, nine, 10, 11, 12,
13, 14, or 15 or more) years; or for the remainder of the patient's
life.
It is understood that the exemplary dosing schedules in Tables 1 or
2 can be adjusted (in frequency, duration, and/or in total amount
of antibody administered) by a medical practitioner as necessary in
such a way as to maintain complete or substantially complete
inhibition of systemic complement activity in the patient for the
duration of the dosing regime.
[0069] In another aspect, the disclosure features a method for
treating a complement-associated disorder, the method including
chronically administering to a patient in need thereof an anti-C5
antibody in an amount and with a frequency that are effective to
maintain a concentration of at least 40 (e.g., at least 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, 75, 80, 85, 90, 95, 100,
110, or 120 or more) .mu.g of the antibody per milliliter of the
patient's blood, wherein the patient has, is suspected of having,
or is at risk for developing a complement-associated disorder with
the proviso that the disorder is not paroxysmal nocturnal
hemoglobinuria.
[0070] In some embodiments, the anti-C5 antibody is administered to
the patient at least once every two weeks. In some embodiments, the
anti-C5 antibody is administered to the patient once per week. In
some embodiments, the anti-C5 antibody is administered to the
patient for at least 9 weeks (e.g., 9, 10, 11, 12, 13, 14, 15, 16,
17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33,
34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50,
51, or 52 weeks; 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months;
or 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5,
9, 9.5, 10, 10.5, or 12 years or for the remainder of the patient's
life) under the following dosing schedule: at least 800 (e.g., at
least 810, 820, 830, 840, 850, 860, 870, 880, 890, 900, 910, 920,
930, 940, 950, 960, 970, 980, 990, 1000, 1100, or 1200 or more) mg
of the anti-C5 antibody, once per week for four consecutive weeks;
at least 800 (e.g., at least 810, 820, 830, 840, 850, 860, 870,
880, 890, 900, 910, 920, 930, 940, 950, 960, 970, 980, 990, 1000,
1100, or 1200 or more) mg of the anti-C5 antibody once during the
fifth week; and at least 800 (e.g., at least 810, 820, 830, 840,
850, 860, 870, 880, 890, 900, 910, 920, 930, 940, 950, 960, 970,
980, 990, 1000, 1100, or 1200 or more) mg of the anti-C5 antibody
bi-weekly thereafter for the remainder of the dosing schedule. In
preferred embodiments, at least 900) mg of the anti-C5 antibody is
administered to the patient, once per week for four weeks; at least
1200 mg is administered to the patient during the fifth week; and
at least 1200 mg of the anti-C5 antibody is administered to the
patient bi-weekly thereafter for the remainder of the chronic
dosing schedule.
[0071] In yet another aspect, the disclosure features a method for
transplanting an organ or tissue. The method includes transplanting
an organ or tissue into a patient in need thereof, wherein prior to
and chronically following the transplanting an inhibitor of human
complement is administered to the patient in an amount and with a
frequency effective to substantially inhibit systemic complement
activity in the patient. The complement inhibitor can be, e.g., a
C5 inhibitor such as an anti-C5 antibody (e.g., eculizumab). As
described herein, the C5 inhibitor (e.g., the anti-C5 antibody) can
be administered in an amount and with a frequency to maintain a
concentration of at least 0.7 bivalent C5 inhibitor molecule(s) (or
at least 1.5 monovalent C5 inhibitor molecule(s)) per every C5
molecule in the patient's blood. In some embodiments, the C5
inhibitor (e.g., the anti-C5 antibody) can be administered to the
patient in an amount and with a frequency to maintain a
concentration of at least at least 40 (e.g., 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, 75, 80, 85, 90, 95, 100, 110, or
120 or more) .mu.g of the inhibitor (e.g., the anti-C5 antibody) in
the patient's blood. In some embodiments, at least 800 (e.g., at
least 810, 820, 830, 840, 850, 860, 870, 880, 890, 900, 910, 920,
930, 940, 950, 960, 970, 980, 990, 1000, 1100, or 1200 or more) mg
of the anti-C5 antibody (e.g., eculizumab) is administered to the
patient less than 24 (e.g., less than 23, 22, 21, 20, 19, 18, 17,
16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, or less than 2)
hours prior to transplanting the organ or tissue to the patient. In
some embodiments, the methods can also include, prior to the
transplanting, contacting (e.g., soaking) the organ or tissue with
a C5 inhibitor (e.g., an anti-C5 antibody such as eculizumab) for
an amount of time and under conditions that inhibit complement
activation in the organ or tissue upon transplantation. The organ
can be, e.g., skin, a kidney, heart, lung, limb (e.g., finger or
toe), eye, stem cell population, bone marrow, vascular tissue,
muscle, nervous tissue, or liver. The patient can have, be at risk
for developing, or be suspected of having aHUS. In some
embodiments, at least 700 (e.g., at least 710, 720, 730, 740, 750,
760, 770, 780, 790, 800, 810, 820, 830, 840, 850, 860, 870, 880,
890, 900, 910, 920, 930, 940, 950, 960, 970, 980, 990, 1000, 1100,
or 1200 or more) mg of an anti-C5 antibody is administered to the
patient less than 24 (e.g., less than 23, 22, 21, 20, 19, 18, 17,
16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, or less than 2)
hours following the transplanting. In some embodiments, the anti-C5
antibody is chronically administered to the patient following the
transplanting. For example, an anti-C5 antibody can be chronically
administered to the patient for at least 9 weeks (e.g., 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,
29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45,
46, 47, 48, 49, 50, 51, or 52 weeks; 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
11, or 12 months; or 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6,
6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 10.5, or 12 years or for the
remainder of the patient's life) under the following dosing
schedule: at least 700 (e.g., at least 710, 720, 730, 740, 750,
760, 770, 780, 790, 800, 810, 820, 830, 840, 850, 860, 870, 880,
890, 900, 910, 920, 930, 940, 950. 960, 970, 980, 990, 1000, 1100,
or 1200 or more) mg of the anti-C5 antibody less than 24 hours
after transplanting the organ or tissue; at least 700 (e.g., at
least 710, 720, 730, 740, 750, 760, 770, 780, 790, 800, 810, 820,
830, 840, 850, 860, 870, 880, 890, 900, 910, 920, 930, 940, 950,
960, 970, 980, 990, 1000, 1100, or 1200 or more) mg of the anti-C5
antibody once per week for four weeks after the initial
post-transplant dose; at least 700 (e.g., at least 710, 720, 730,
740, 750, 760, 770, 780, 790, 800, 810, 820, 830, 840, 850, 860,
870, 880, 890, 900, 910, 920, 930, 940, 950, 960, 970, 980, 990,
1000, 1100, or 1200 or more) mg of the anti-C5 antibody once during
the fifth week; and at least 700 (e.g., at least 710, 720, 730,
740, 750, 760, 770, 780, 790, 800, 810, 820, 830, 840, 850, 860,
870, 880, 890, 900, 910, 920, 930, 940, 950, 960, 970, 980, 990,
1000, 1100, or 1200 or more) mg of the anti-C5 antibody bi-weekly
thereafter for the remainder of the dosing schedule. In preferred
embodiments, an anti-C5 antibody is administered to a patient
undergoing a transplant operation under the following dosing
schedule: at least 1200 mg of the anti-C5 antibody is administered
to the patient less than 24 hours prior to the transplanting; at
least 900 mg of the anti-C5 antibody is administered to the patient
within 24 hours after the transplanting; at least 1200 mg of the
anti-C5 antibody is administered to the patient once a week for
four weeks following the first post-operation administration of the
anti-C5 antibody; 1200 mg administered to the patient on the fifth
week following the first post-operation administration of the
anti-C5 antibody; and at least 1200 mg of the anti-C5 antibody
administered to the patient bi-weekly thereafter for the remainder
of the chronic treatment regimen.
[0072] In some embodiments, the methods can further include
administering to the patient one or more immunosuppressive agents
such as, but not limited to, rapamycin, cyclosporine A, an
anti-IL-2 agent, OKT3, and tacrolimus. The one or more
immunosuppressive agents can be administered prior to, during, or
following the transplanting. The one or more immunosuppressive
agents can also be administered before, concurrently with, or
following administration of the C5 inhibitor.
[0073] The disclosure also features a method for reducing
complement-mediated injury to an organ or a tissue when
transplanted into a patient. The method includes, prior to
transplanting an organ or tissue to a patient in need thereof,
contacting the organ or tissue with a pharmaceutical solution
comprising an inhibitor of C5 for a period of time and under
conditions which reduce complement-mediated injury to the organ or
tissue when transplanted into the patient. The C5 inhibitor can
also be administered to the patient prior to, during, and/or after
the transplanting of the organ or tissue. The solution can also
contain one or more immunosuppressive agents such as, but not
limited to, rapamycin, cyclosporine A, an anti-IL-2 agent, OKT3,
and tacrolimus.
[0074] The inventors have also discovered that in patients who have
had severe complement-associated disorders such as CAPS and APS and
entered remission, there still remains in the patients a low level
of complement activity that predisposes the patients for relapse or
recurrence. As noted above, recurrence of symptoms in patients who
have had these severe disorders can present immediate and sometimes
irreversible injury to major organs such as the kidney. Thus, while
the disclosure is in no way limited by one particular theory or
mechanism of action, the inventors assert that in order to prevent
sudden relapse or recurrence, a patient with a
complement-associated disorder (e.g., aHUS and CAPS) should be
chronically treated with a C5 inhibitor even after one or more
symptoms of the disorder have been ameliorated and/or even after
the patient enters a clinical remission. Thus, in yet another
aspect, the disclosure features a method for treating a
complement-associated disorder with the proviso that the disorder
is not paroxysmal nocturnal hemoglobinuria. The method includes
administering to a patient afflicted with a complement-associated
disorder a C5 inhibitor (e.g., an anti-C5 antibody such as
eculizumab) in an amount effective to treat the
complement-associated disorder. The C5 inhibitor is administered to
the patient even after one or more (e.g., two, three, four, five,
or six or more) symptoms of the disorder have been ameliorated. In
some embodiments, the C5 inhibitor is administered to the patient
even after one or more symptoms have been completely ameliorated.
In some embodiments, the C5-inhibitor is administered to the
patient even after the patient has entered clinical remission. The
C5 inhibitor can be administered, e.g., chronically administered,
to the patient for at least 8 weeks (e.g., 9, 10, 11, 12, 13, 14,
15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31,
32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48,
49, 50, 51, or 52 weeks; 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12
months; or 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5,
8, 8.5, 9, 9.5, 10, 10.5, or 12 years or for the remainder of the
patient's life) after one or more symptoms have been ameliorated in
the patient and/or the patient enters clinical remission. The
complement-associated disorder can be any of those described
herein, e.g., membranoproliferative glomerulonephritis, Degos
disease, atypical hemolytic uremic syndrome, antibody-mediated
rejection, HELLP syndrome, and catastrophic antiphospholipid
syndrome.
[0075] While the disclosure is in no way limited by a particular
theory or mechanism of action, based on the observations of the
effect of eculizumab in, e.g., aHUS patients, the inventors have
concluded that the biological activity of complement component C5a
may substantially contribute to the vasoconstriction and
hypertension associated with aHUS. Accordingly, inhibition of C5a
using a C5a inhibitor is useful for treating aHUS and/or
ameliorating the vasoconstriction and hypertension associated with
aHUS. The method includes administering to a patient in need
thereof an inhibitor of complement component C5a in an amount
effective to treat aHUS in the patient. In some embodiments, the
vasoconstriction and hypertension associated with aHUS can be
ameliorated within less than two months (e.g., less than 7, 6, 5,
4, 3, or 2 weeks; less than 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4,
3, 2, or 1 day(s); or less than 12, 11, 10, 9, 8, 7, 6 or even less
than 5 hours) after administering the C5a inhibitor. In some
embodiments, the C5a inhibitor is an antibody (or antigen-binding
fragment thereof) that binds to a human C5a protein or a fragment
thereof having an amino acid sequence that contains, or consists
of, at least four (e.g., at least four, five, six, seven, eight,
nine, 10, 11, 12, 13, 14, 15, 16, or 17 or more) consecutive amino
acids depicted in any one of SEQ ID NOs: 12-25. In some
embodiments, the inhibitor is an antibody that binds to human C5a
protein having the amino acid sequence depicted in SEQ ID NO: 12.
The C5a inhibitor does not inhibit the cleavage of C5 into fragment
C5a and C5b. The C5a inhibitor also does not inhibit C5b or the
formation of the membrane attack complex. As described herein, in
some embodiments, the C5a inhibitor (e.g., an anti-C5a antibody)
can inhibit the interaction between C5a and a C5a receptor (e.g.,
C5aR or C5L2). In some embodiments, the antibody can be a
monoclonal antibody, a single-chain antibody, a humanized antibody,
a fully human antibody, a polyclonal antibody, a recombinant
antibody, a diabody, a chimerized or chimeric antibody, a
deimmunized human antibody, a fully human antibody, a single chain
antibody, an Fv fragment, an Fd fragment, an Fab fragment, an Fab'
fragment, or an F(ab').sub.2 fragment.
[0076] In embodiments of any of the methods described herein where
the complement-associated disorder is aHUS, the aHUS can be
genetic, acquired, or idiopathic form. In some embodiments, the
aHUS can be complement factor H (CFH)-associated aHUS (e.g., aHUS
associated with mutations in factor H or autoantibodies that bind
to and inactivate factor H), membrane cofactor protein
(MCP)-associated aHUS, complement factor I (CFI)-associated aHUS,
C4b-binding protein (C4BP)-associated aHUS, complement factor
B-(CFB)-associated aHUS, a vWF disorder, or aHUS associated with
any other mutations in the alternative pathway of complement
activation causing low levels of C3 as a result of increased C3
consumption.
[0077] In some embodiments, any of the methods described herein can
further include identifying the patient as one having, suspected of
having, or at risk for developing, aHUS. In some embodiments, any
of the methods described herein can include, after the
administering, monitoring the patient for an improvement in one or
more symptoms of aHUS. In some embodiments of any of the methods
described herein, the C5a inhibitor can be administered to the
patient prior to, during, or following a plasma therapy (e.g.,
plasma exchange or plasma infusion). In some embodiments,
administration of the C5a inhibitor to the patient can alleviate
the need for plasma therapy by a patient. For example, in some
embodiments, administration (e.g., chronic administration) of the
C5a inhibitor to the patient can alleviate or substantially reduce
the need for plasma therapy by a patient for at least 2 months
(e.g., 3 months, 4 months, 5 months, 6 months, 7 months, 8 months,
9 months, 10 months, 11 months, or 12 months or 1, 2, 3, 4, 5, or 6
years or more). In some embodiments, any of the methods described
herein can include administering to the patient one or more
additional active agents useful for treating typical HUS or aHUS.
The one or more additional active agents can be, e.g., selected
from the group consisting of anti-hypertensives, anti-platelet
agents, prostacyclin, fibrinolytic agents, and anti-oxidants.
[0078] In some embodiments, the human is an infant. The infant can
be, e.g., 0.5 (e.g., 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6,
6.5, 7, 7.5, 8, 8.5, 9, or 9.5) years old. The infant can be less
than 10 (e.g., less than 9.5, 9, 8.5, 8, 7.5, 7, 6.5, 6, 5.5, 5,
4.5, 4, 3.5, 3, 2.5, 2, 1.5, 1, or less than 1) year(s) old.
[0079] In some embodiments of any of the methods described herein,
the complement-associated disorder is not paroxysmal nocturnal
hemoglobinuria.
[0080] "Polypeptide," "peptide," and "protein" are used
interchangeably and mean any peptide-linked chain of amino acids,
regardless of length or post-translational modification. The
complement component C5 proteins described herein can contain or be
wild-type proteins or can be variants that have not more than 50
(e.g., not more than one, two, three, four, five, six, seven,
eight, nine, ten, 12, 15, 20, 25, 30, 35, 40, or 50) conservative
amino acid substitutions. Conservative substitutions typically
include substitutions within the following groups: glycine and
alanine; valine, isoleucine, and leucine; aspartic acid and
glutamic acid; asparagine, glutamine, serine and threonine; lysine,
histidine and arginine; and phenylalanine and tyrosine.
[0081] The human complement component C5 proteins described herein
also include "antigenic peptide fragments" of the proteins, which
are shorter than full-length and/or immature (pre-pro) C5 proteins,
but retain at least 10% (e.g., at least 10%, at least 15%, at least
20%, at least 25%, at least 30%, at least 35%, at least 40%, at
least 50%, at least 55%, at least 60%, at least 70%, at least 80%,
at least 90%, at least 95%, at least 98%, at least 99%, at least
99.5%, or 100% or more) of the ability of the full-length protein
to induce an antigenic response in a mammal (see below under
"Methods for Producing an Antibody"). Antigenic peptide fragments
of a C5 protein include terminal as well internal deletion variants
of the protein. Deletion variants can lack one, two, three, four,
five, six, seven, eight, nine, ten, 11, 12, 13, 14, 15, 16, 17, 18,
19, or 20 amino acid segments (of two or more amino acids) or
non-contiguous single amino acids. Antigenic peptide fragments can
be at least 6 (e.g., at least 7, 8, 9, 10, 11, 12, 13, 14, 15, 16,
17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33,
34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50,
55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150,
160, 170, 180, 190, 200, 250, 300, 350, 400, 450, 500, or 600 or
more) amino acid residues in length (e.g., at least 6 contiguous
amino acid residues in any one of SEQ ID NOS:1-11). In some
embodiments, an antigenic peptide fragment of a human C5 protein
has fewer than 500 (e.g., fewer than 450, 400, 350, 325, 300, 275,
250, 225, 200, 190, 180, 170, 160, 150, 140, 130, 120, 110, 100,
95, 90, 85, 80, 75, 70, 65, 60, 55, 50, 49, 48, 47, 46, 45, 44, 43,
42, 41, 40, 39, 38, 37, 36, 35, 34, 33, 32, 31, 30, 29, 28, 27, 26,
25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9,
8, 7, or 6) amino acid residues in length (e.g., fewer than 500
contiguous amino acid residues in any one of SEQ ID NOS:1-11). In
some embodiments, an antigenic peptide fragment of a full-length,
immature human C5 protein (prepro-C5 protein) has at least 6, but
fewer than 500, amino acid residues in length.
[0082] In some embodiments, the human complement component C5
protein can have an amino acid sequence that is, or is greater
than, 70 (e.g., 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83,
84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, or
100) % identical to the human C5 protein having the amino acid
sequence depicted in SEQ ID NO:1 (see below).
[0083] Percent (%) amino acid sequence identity is defined as the
percentage of amino acids in a candidate sequence that are
identical to the amino acids in a reference sequence, after
aligning the sequences and introducing gaps, if necessary, to
achieve the maximum percent sequence identity. Alignment for
purposes of determining percent sequence identity can be achieved
in various ways that are within the skill in the art, for instance,
using publicly available computer software such as BLAST, BLAST-2,
ALIGN, ALIGN-2 or Megalign (DNASTAR) software. Appropriate
parameters for measuring alignment, including any algorithms needed
to achieve maximal alignment over the full-length of the sequences
being compared can be determined by known methods.
[0084] Amino acid sequences for exemplary human C5 proteins as well
as antigenic peptide fragments thereof are known in the art and are
set forth below.
[0085] As used throughout the present disclosure, the term
"antibody" refers to a whole or intact antibody (e.g., IgM, IgG,
IgA, IgD, or IgE) molecule that is generated by any one of a
variety of methods that are known in the art and described herein.
The term "antibody" includes a polyclonal antibody, a monoclonal
antibody, a chimerized or chimeric antibody, a humanized antibody,
a deimmunized human antibody, and a fully human antibody. The
antibody can be made in or derived from any of a variety of
species, e.g., mammals such as humans, non-human primates (e.g.,
monkeys, baboons, or chimpanzees), horses, cattle, pigs, sheep,
goats, dogs, cats, rabbits, guinea pigs, gerbils, hamsters, rats,
and mice. The antibody can be a purified or a recombinant
antibody.
[0086] As used herein, the term "antibody fragment,"
"antigen-binding fragment," or similar terms refer to fragment of
an antibody that retains the ability to bind to an antigen (e.g., a
complement component C5 protein), e.g., a single chain antibody, a
single chain Fv fragment (scFv), an Fd fragment, an Fab fragment,
an Fab' fragment, or an F(ab').sub.2 fragment. An scFv fragment is
a single polypeptide chain that includes both the heavy and light
chain variable regions of the antibody from which the scFv is
derived. In addition, diabodies (Poljak (1994) Structure 2(12):
1121-1123; Hudson et al. (1999) J. Immunol. Methods 23(1-2):
177-189, the disclosures of each of which are incorporated herein
by reference in their entirety) and intrabodies (Huston et al.
(2001) Hum. Antibodies 10(3-4):127-142; Wheeler et al. (2003) Mol
Ther 8(3):355-366; Stocks (2004) Drug Discov. Today 9(22): 960-966,
the disclosures of each of which are incorporated herein by
reference in their entirety) that bind to a complement component C5
protein can be incorporated into the compositions, and used in the
methods, described herein.
[0087] Unless otherwise defined, all technical and scientific terms
used herein have the same meaning as commonly understood by one of
ordinary skill in the art to which this disclosure pertains. In
case of conflict, the present document, including definitions, will
control. Preferred methods and materials are described below,
although methods and materials similar or equivalent to those
described herein can also be used in the practice or testing of the
presently disclosed methods and compositions. All publications,
patent applications, patents, and other references mentioned herein
are incorporated by reference in their entirety.
[0088] Other features and advantages of the present disclosure,
e.g., methods for treating or preventing a complement-associated
disorder, will be apparent from the following description, the
examples, and from the claims.
DETAILED DESCRIPTION
[0089] The present disclosure provides compositions containing an
inhibitor of human complement component C5 (e.g., an antibody that
binds to a human complement component C5 protein or a
biologically-active fragment thereof such as C5a and C5b) and
methods for using the compositions to treat or prevent a
complement-mediated disorder in a human. While in no way intended
to be limiting, exemplary compositions (e.g., pharmaceutical
compositions and formulations) and methods for using the
compositions are elaborated on below.
Compositions
[0090] The compositions described herein contain an inhibitor of
human complement. Any compound which binds to or otherwise blocks
the generation and/or activity of any of the human complement
components may be utilized in accordance with the present
disclosure. For example, an inhibitor of complement can be, e.g., a
small molecule, a nucleic acid or nucleic acid analog, a
peptidomimetic, or a macromolecule that is not a nucleic acid or a
protein. These agents include, but are not limited to, small
organic molecules, RNA aptamers, L-RNA aptamers, Spiegelmers,
antisense compounds, double stranded RNA, small interfering RNA,
locked nucleic acid inhibitors, and peptide nucleic acid
inhibitors. In some embodiments, a complement inhibitor may be a
protein or protein fragment.
[0091] In some embodiments, the compositions contain antibodies
specific to a human complement component. Some compounds include
antibodies directed against complement components C1, C2, C3, C4,
C5 (or a fragment thereof; see below), C6, C7, C8, C9, Factor D,
Factor B, Factor P, MBL, MASP-1, and MASP-2, thus preventing the
generation of the anaphylatoxic activity associated with C5a and/or
preventing the assembly of the membrane attack complex associated
with C5b.
[0092] The compositions can also contain naturally occurring or
soluble forms of complement inhibitory compounds such as CR1,
LEX-CR1, MCP, DAF, CD59, Factor H, cobra venom factor, FUT-175,
complestatin, and K76 COOH. Other compounds which may be utilized
to bind to or otherwise block the generation and/or activity of any
of the human complement components include, but are not limited to,
proteins, protein fragments, peptides, small molecules, RNA
aptamers including ARC 187 (which is commercially available from
Archemix Corporation, Cambridge, Mass.), L-RNA aptamers,
spiegelmers, antisense compounds, serine protease inhibitors,
molecules which may be utilized in RNA interference (RNAi) such as
double stranded RNA including small interfering RNA (siRNA), locked
nucleic acid (LNA) inhibitors, peptide nucleic acid (PNA)
inhibitors, etc.
[0093] In some embodiments, the complement inhibitor inhibits the
activation of complement. For example, the complement inhibitor can
bind to and inhibit the complement activation activity of C1 (e.g.,
C1q, C1r, or C1s) or the complement inhibitor can bind to and
inhibit (e.g., inhibit cleavage of) C2. C3, or C4. In some
embodiments, the inhibitor inhibits formation or assembly of the C3
convertase and/or C5 convertase of the alternative and/or classical
pathways of complement. In some embodiments, the complement
inhibitor inhibits terminal complement formation, e.g., formation
of the C5b-9 membrane attack complex. For example, an antibody
complement inhibitor may include an anti-C5 antibody. Such anti-C5
antibodies may directly interact with C5 and/or C5b, so as to
inhibit the formation of and/or physiologic function of C5b.
[0094] In some embodiments, the compositions described herein can
contain an inhibitor of human complement component C5 (e.g., an
antibody, or antigen-binding fragment thereof, that binds to a
human complement component C5 protein or a biologically-active
fragment thereof such as C5a or C5b). As used herein, an "inhibitor
of complement component C5" is any agent that inhibits: (i) the
expression, or proper intracellular trafficking or secretion by a
cell, of a complement component C5 protein; (ii) the activity of C5
cleavage fragments C5a or C5b (e.g., the binding of C5a to its
cognate cellular receptors or the binding of C5b to C6 and/or other
components of the terminal complement complex; see above); (iii)
the cleavage of a human C5 protein to form C5a and C5b; or (iv) the
proper intracellular trafficking of, or secretion by a cell, of a
complement component C5 protein. Inhibition of complement component
C5 protein expression includes: inhibition of transcription of a
gene encoding a human C5 protein; increased degradation of an mRNA
encoding a human C5 protein; inhibition of translation of an mRNA
encoding a human C5 protein; increased degradation of a human C5
protein; inhibition of proper processing of a pre-pro human C5
protein; or inhibition of proper trafficking or secretion by a cell
of a human C5 protein. Methods for determining whether a candidate
agent is an inhibitor of human complement component C5 are known in
the art and described herein.
[0095] An inhibitor of human complement component C5 can be, e.g.,
a small molecule, a polypeptide, a polypeptide analog, a nucleic
acid, or a nucleic acid analog.
[0096] "Small molecule" as used herein, is meant to refer to an
agent, which has a molecular weight of less than about 6 kDa and
most preferably less than about 2.5 kDa. Many pharmaceutical
companies have extensive libraries of chemical and/or biological
mixtures comprising arrays of small molecules, often fungal,
bacterial, or algal extracts, which can be screened with any of the
assays of the application. This application contemplates using,
among other things, small chemical libraries, peptide libraries, or
collections of natural products. Tan et al. described a library
with over two million synthetic compounds that is compatible with
miniaturized cell-based assays (J. Am. Chem. Soc. (1998)
120:8565-8566). It is within the scope of this application that
such a library may be used to screen for inhibitors of human
complement component C5. There are numerous commercially available
compound libraries, such as the Chembridge DIVERSet. Libraries are
also available from academic investigators, such as the Diversity
set from the NCI developmental therapeutics program. Rational drug
design may also be employed. For example, rational drug design can
employ the use of crystal or solution structural information on the
human complement component C5 protein. See. e.g., the structures
described in Hagemann et al. (2008) J Biol Chem 283(12):7763-75 and
Zuiderweg et al. (1989) Biochemistry 28(1): 172-85. Rational drug
design can also be achieved based on known compounds, e.g., a known
inhibitor of C5 (e.g., an antibody, or antigen-binding fragment
thereof, that binds to a human complement component C5
protein).
[0097] Peptidomimetics can be compounds in which at least a portion
of a subject polypeptide is modified, and the three dimensional
structure of the peptidomimetic remains substantially the same as
that of the subject polypeptide. Peptidomimetics may be analogues
of a subject polypeptide of the disclosure that are, themselves,
polypeptides containing one or more substitutions or other
modifications within the subject polypeptide sequence.
Alternatively, at least a portion of the subject polypeptide
sequence may be replaced with a non-peptide structure, such that
the three-dimensional structure of the subject polypeptide is
substantially retained. In other words, one, two or three amino
acid residues within the subject polypeptide sequence may be
replaced by a non-peptide structure. In addition, other peptide
portions of the subject polypeptide may, but need not, be replaced
with a non-peptide structure. Peptidomimetics (both peptide and
non-peptidyl analogues) may have improved properties (e.g.,
decreased proteolysis, increased retention or increased
bioavailability). Peptidomimetics generally have improved oral
availability, which makes them especially suited to treatment of
disorders in a human or animal. It should be noted that
peptidomimetics may or may not have similar two-dimensional
chemical structures, but share common three-dimensional structural
features and geometry. Each peptidomimetic may further have one or
more unique additional binding elements.
[0098] Nucleic acid inhibitors can be used to decrease expression
of an endogenous gene encoding human complement component C5. The
nucleic acid antagonist can be, e.g., an siRNA, a dsRNA, a
ribozyme, a triple-helix former, an aptamer, or an antisense
nucleic acid, siRNAs are small double stranded RNAs (dsRNAs) that
optionally include overhangs. For example, the duplex region of an
siRNA is about 18 to 25 nucleotides in length, e.g., about 19, 20,
21, 22, 23, or 24 nucleotides in length. The siRNA sequences can
be, in some embodiments, exactly complementary to the target mRNA.
dsRNAs and siRNAs in particular can be used to silence gene
expression in mammalian cells (e.g., human cells). See, e.g.,
Clemens et al. (2000) Proc. Natl. Acad. Sci. USA 97:6499-6503;
Billy et al. (2001) Proc. Natl. Acad. Sci. USA 98:14428-14433;
Elbashir et al. (2001) Nature 411:494-8; Yang et al. (2002) Proc.
Natl. Acad. Sci. USA 99:9942-9947, and U.S. Patent Application
Publication Nos. 20030166282, 20030143204, 20040038278, and
20030224432. Anti-sense agents can include, for example, from about
8 to about 80 nucleobases (i.e. from about 8 to about 80
nucleotides), e.g., about 8 to about 50 nucleobases, or about 12 to
about 30 nucleobases. Anti-sense compounds include ribozymes,
external guide sequence (EGS) oligonucleotides (oligozymes), and
other short catalytic RNAs or catalytic oligonucleotides which
hybridize to the target nucleic acid and modulate its expression.
Anti-sense compounds can include a stretch of at least eight
consecutive nucleobases that are complementary to a sequence in the
target gene. An oligonucleotide need not be 100% complementary to
its target nucleic acid sequence to be specifically hybridizable.
An oligonucleotide is specifically hybridizable when binding of the
oligonucleotide to the target interferes with the normal function
of the target molecule to cause a loss of utility, and there is a
sufficient degree of complementarity to avoid non-specific binding
of the oligonucleotide to non-target sequences under conditions in
which specific binding is desired, i.e., under physiological
conditions in the case of in vivo assays or therapeutic treatment
or, in the case of in vitro assays, under conditions in which the
assays are conducted. Hybridization of antisense oligonucleotides
with mRNA (e.g., an mRNA encoding a human C5 protein) can interfere
with one or more of the normal functions of mRNA. The functions of
mRNA to be interfered with include all key functions such as, for
example, translocation of the RNA to the site of protein
translation, translation of protein from the RNA, splicing of the
RNA to yield one or more mRNA species, and catalytic activity which
may be engaged in by the RNA. Binding of specific protein(s) to the
RNA may also be interfered with by antisense oligonucleotide
hybridization to the RNA. Exemplary antisense compounds include DNA
or RNA sequences that specifically hybridize to the target nucleic
acid, e.g., the mRNA encoding a human complement component C5
protein. The complementary region can extend for between about 8 to
about 80 nucleobases. The compounds can include one or more
modified nucleobases.
[0099] Modified nucleobases may include, e.g., 5-substituted
pyrimidines such as 5-iodouracil, 5-iodocytosine, and
C.sub.5-propynyl pyrimidines such as C.sub.5-propynylcytosine and
C.sub.5-propynyluracil. Other suitable modified nucleobases
include, e.g., 7-substituted-8-aza-7-deazapurines and
7-substituted-7-deazapurines such as, for example,
7-iodo-7-deazapurines, 7-cyano-7-deazapurines,
7-aminocarbonyl-7-deazapurines. Examples of these include
6-amino-7-iodo-7-deazapurines, 6-amino-7-cyano-7-deazapurines,
6-amino-7-aminocarbonyl-7-deazapurines,
2-amino-6-hydroxy-7-iodo-7-deazapurines,
2-amino-6-hydroxy-7-cyano-7-deazapurines, and
2-amino-6-hydroxy-7-aminocarbonyl-7-deazapurines. See, e.g., U.S.
Pat. Nos. 4,987,071; 5,116,742; and 5,093,246; "Antisense RNA and
DNA," D. A. Melton, Ed., Cold Spring Harbor Laboratory, Cold Spring
Harbor, N.Y. (1988); Haselhoff and Gerlach (1988) Nature
334:585-59; Helene, C. (1991) Anticancer Drug D 6:569-84; Helene
(1992) Ann. NY. Acad. Sci. 660:27-36; and Maher (1992) Bioassays
14:807-15.
[0100] Aptamers are short oligonucleotide sequences that can be
used to recognize and specifically bind almost any molecule,
including cell surface proteins. The systematic evolution of
ligands by exponential enrichment (SELEX) process is powerful and
can be used to readily identify such aptamers. Aptamers can be made
for a wide range of proteins of importance for therapy and
diagnostics, such as growth factors and cell surface antigens.
These oligonucleotides bind their targets with similar affinities
and specificities as antibodies do (see, e.g., Ulrich (2006) Handb
Exp Pharmacol. 173:305-326).
[0101] In some embodiments, the inhibitor of human C5 is an
antibody, or antigen-binding fragment thereof, which binds to a
human complement component C5 protein. (Hereinafter, the antibody
may sometimes be referred to as an "anti-C5 antibody.")
[0102] In some embodiments, the anti-C5 antibody binds to an
epitope in the human pro-C5 precursor protein. For example, the
anti-C5 antibody can bind to an epitope in the human complement
component C5 protein comprising, or consisting of, the amino acid
sequence depicted in SEQ ID NO:1 (NCBI Accession No. AAA51925 and
Haviland et al., supra).
[0103] An "epitope" refers to the site on a protein (e.g., a human
complement component C5 protein) that is bound by an antibody.
"Overlapping epitopes" include at least one (e.g., two, three,
four, five, or six) common amino acid residue(s).
[0104] In some embodiments, the anti-C5 antibody binds to an
epitope in the human pro-C5 precursor protein lacking the leader
sequence. For example, the anti-C5 antibody can bind to an epitope
in the human complement component C5 protein comprising, or
consisting of, the amino acid sequence depicted in SEQ ID NO:2,
which is a human C5 protein lacking the amino terminal leader
sequence.
[0105] In some embodiments, the anti-C5 antibody can bind to an
epitope in the alpha chain of the human complement component C5
protein. For example, the anti-C5 antibody can bind to an epitope
within, or overlapping with, a protein having the amino acid
sequence depicted in SEQ ID NO:3, which is the human complement
component C5 alpha chain protein. Antibodies that bind to the alpha
chain of C5 are described in, for example, Ames et al. (1994) J
Immunol 152:4572-4581.
[0106] In some embodiments, the anti-C5 antibody can bind to an
epitope in the beta chain of the human complement component C5
protein. For example, the anti-C5 antibody can bind to an epitope
within, or overlapping with, a protein having the amino acid
sequence depicted in SEQ ID NO:4, which is the human complement
component C5 beta chain protein. Antibodies that bind to the C5
beta chain are described in, e.g., Moongkarndi et al. (1982)
Immunobiol. 162:397; Moongkarndi et al. (1983) Immunobiol. 165:323;
and Mollnes et al. (1988) Scand. J. Immunol. 28:307-312.
[0107] In some embodiments, the anti-C5 antibody can bind to an
epitope within, or overlapping with, an antigenic peptide fragment
of a human complement component C5 protein. For example, the
anti-C5 antibody can bind to an epitope within, or overlapping
with, an antigen peptide fragment of a human complement component
C5 protein, the fragment containing, or consisting of, the
following amino acid sequence: VIDHQGTKSSKCVRQKVEGSS (SEQ ID NO:5)
or KSSKC (SEQ ID NO:6).
[0108] In some embodiments, the anti-C5 antibody can bind to an
epitope within, or overlapping with, a fragment of a human
complement component C5 protein, the fragment containing, or
consisting of, any one of the following amino acid sequences (which
are exemplary antigenic fragments of SEQ ID NO:1):
TABLE-US-00003 (SEQ ID NO: 7)
NFSLETWFGKEILVKTLRVVPEGVKRESYSGVTLDPRGIYGTISRRKEFP
YRIPLDLVPKTEIKRILSVKGLLVGEILSAVLSQEGINILTHLPKGSAEA
ELMSVVPVFYVFHYLETGNHWNIFHSD; (SEQ ID NO: 8)
SESPVIDHQGTKSSKCVRQKVEGSSSHLVTFTVLPLEIGLHNINFSLETW
FGKEILVKTLRVVPEGVKRESYSGVTLDPRGIYGTISRRKEFPYRIPLDL
VPKTEIKRILSVKGLLVGEILSAVLSQEGINILTHLPKGSAEAELMSVVP
VFYVFHYLETGNHWNIFHSDPLIEKQKLKKKLKEGMLSIMSYRNADYSY S; (SEQ ID NO: 9)
SHKDMQLGRLHMKTLLPVSKPEIRSYFPES; (SEQ ID NO: 10)
SHKDMQLGRLHMKTLLPVSKPEIRSYFPESWLWEVHLVPRRKQLQFALPD
SLTTWEIQGIGISNTGICVADTVKAKVFKDVFLEMNIPYSVVRGEQIQLK
GTVYNYRTSGMQFCVKMSAVEGICTSESPVIDHQGTKSSKCVRQKVEGSS
SHLVTFTVLPLEIGLHNINFSLETWFGKEILVKTLRVVPEGVKRESYSGV
TLDPRGIYGTISRRKEFPYRIPLDLVPKTEIKRILSVKGLLVGEILSAVL
SQEGINILTHLPKGSAEAELMSVVPVFYVFHYLETGNHWNIFHSDPLIEK
QKLKKKLKEGMLSIMSYRNADYSYS; and (SEQ ID NO: 11)
DHQGTKSSKCYRQKVEG.
[0109] Additional exemplary antigenic fragments of human complement
component C5 are disclosed in, e.g., U.S. Pat. No. 6,355,245, the
disclosure of which is incorporated herein by reference.
[0110] In some embodiments, the anti-C5 antibody specifically binds
to a human complement component C5 protein (e.g., the human C5
protein having the amino acid sequence depicted in SEQ ID NO:1).
The terms "specific binding" or "specifically binds" refer to two
molecules forming a complex (e.g., a complex between an antibody
and a complement component C5 protein) that is relatively stable
under physiologic conditions. Typically, binding is considered
specific when the association constant (K.sub.a) is higher than
10.sup.6 M.sup.-1. Thus, an antibody can specifically bind to a C5
protein with a K.sub.a of at least (or greater than) 10.sup.6
(e.g., at least or greater than 10.sup.7, 10.sup.8, 10.sup.9,
10.sup.10, 10.sup.11, 10.sup.12, 10.sup.13, 10.sup.14, or 10.sup.15
or higher) M.sup.-1. Examples of antibodies that specifically bind
to a human complement component C5 protein are described in, e.g.,
U.S. Pat. No. 6,355,245, the disclosure of which is incorporated
herein by reference in its entirety.
[0111] Methods for determining whether an antibody binds to a
protein antigen and/or the affinity for an antibody to a protein
antigen are known in the art. For example, the binding of an
antibody to a protein antigen can be detected and/or quantified
using a variety of techniques such as, but not limited to, Western
blot, dot blot, plasmon surface resonance method (e.g., BIAcore
system; Pharmacia Biosensor AB, Uppsala, Sweden and Piscataway.
N.J.), or enzyme-linked immunosorbent assays (ELISA). See, e.g.,
Harlow and Lane (1988) "Antibodies: A Laboratory Manual" Cold
Spring Harbor Laboratory Press, Cold Spring Harbor, N.Y.; Benny K.
C. Lo (2004) "Antibody Engineering: Methods and Protocols," Humana
Press (ISBN: 1588290921); Borrebaek (1992) "Antibody Engineering, A
Practical Guide," W.H. Freeman and Co., NY; Borrebaek (1995)
"Antibody Engineering," 2.sup.nd Edition, Oxford University Press,
NY, Oxford; Johne et al. (1993) J. Immunol. Meth. 160:191-198;
Jonsson et al. (1993) Ann. Biol. Clin. 51:19-26; and Jonsson et al.
(1991) Biotechniques 11:620-627. See also, U.S. Pat. No.
6,355,245.
[0112] In some embodiments, the anti-C5 antibody can crossblock
binding of another antibody that binds to an epitope within, or
overlapping with, a human complement component C5 protein. In some
embodiments, the anti-C5 antibody can crossblock binding of an
antibody that binds to an epitope within, or overlapping with, a
peptide fragment of a human complement component C5 protein. The
peptide fragment can be a fragment of a human complement component
C5 protein having the amino acid sequence depicted in any one of
SEQ ID NOS:1-11. For example, the peptide fragment can contain, or
consist of, the following amino acid sequence:
TABLE-US-00004 (SEQ ID NO: 5) VIDHQGTKSSKCVRQKVEGSS.
[0113] As used herein, the term "crossblocking antibody" refers to
an antibody that lowers the amount of binding of anti-C5 antibody
to an epitope on a complement component C5 protein relative to the
amount of binding of the anti-C5 antibody to the epitope in the
absence of the antibody. Suitable methods for determining whether a
first antibody crossblocks binding of a second antibody to an
epitope are known in the art. For example, crossblocking antibodies
can be identified by comparing the binding of the 5G1.1 anti-C5
monoclonal antibody (produced by the hybridoma cell line ATCC
designation HB-11625; see U.S. Pat. No. 6,355,245) in the presence
and absence of a test antibody. Decreased binding of the 5G1.1
antibody in the presence of the test antibody as compared to
binding of the 5G1.1 antibody in the absence of the test antibody
indicates the test antibody is a crossblocking antibody.
[0114] Methods for identifying the epitope to which a particular
antibody (e.g., an anti-C5 antibody) binds are also known in the
art. For example, the binding epitope of an anti-C5 antibody can be
identified by measuring the binding of the antibody to several
(e.g., three, four, five, six, seven, eight, nine, 10, 15, 20, or
30 or more) overlapping peptide fragments of a complement component
C5 protein (e.g., several overlapping fragments of a protein having
the amino acid sequence depicted in any one of SEQ ID NOs:1-11).
Each of the different overlapping peptides is then bound to a
unique address on a solid support, e.g., separate wells of a
multi-well assay plate. Next, the anti-C5 antibody is interrogated
by contacting it to each of the peptides in the assay plate for an
amount of time and under conditions that allow for the antibody to
bind to its epitope. Unbound anti-C5 antibody is removed by washing
each of the wells. Next, a detectably-labeled secondary antibody
that binds to the anti-C5 antibody, if present in a well of the
plate, is contacted to each of the wells, and unbound secondary
antibody is removed by washing steps. The presence or amount of the
detectable signal produced by the detectably-labeled secondary
antibody in a well is an indication that the anti-C5 antibody binds
to the particular peptide fragment associated with the well. See,
e.g., Harlow and Lane (supra), Benny K. C. Lo (supra), and U.S.
Patent Application Publication No. 20060153836, the disclosure of
which is incorporated by reference in its entirety. A particular
epitope to which an antibody binds can also be identified using
BIAcore chromatographic techniques (see, e.g., Pharmacia
BIAtechnology Handbook, "Epitope Mapping," Section 6.3.2, (May
1994); and Johne et al. (1993) J. Immunol. Methods
160:20191-8).
[0115] The anti-C5 antibodies described herein can have activity in
blocking the generation or activity of the C5a and/or C5b active
fragments of a complement component C5 protein (e.g., a human C5
protein). Through this blocking effect, the anti-C5 antibodies
inhibit, e.g., the proinflammatory effects of C5a and the
generation of the C5b-9 membrane attack complex (MAC) at the
surface of a cell. Anti-C5 antibodies that have the ability to
block the generation of C5a are described in, e.g., Moongkarndi et
al. (1982) Immunobiol. 162:397 and Moongkarndi et al. (1983)
Immunobiol. 165:323.
[0116] In some embodiments, an anti-C5 antibody, or antigen-binding
fragment thereof, can reduce the ability of a C5 protein to bind to
human complement component C3b (e.g., C3b present in an AP or CP C5
convertase complex) by greater than 50 (e.g., greater than 55, 60,
65, 70, 75, 80, 85, 90, or 95 or more) %. In some embodiments, upon
binding to a C5 protein, the anti-C5 antibody or antigen-binding
fragment thereof can reduce the ability of the C5 protein to bind
to complement component C4b (e.g., C4b present in a CP C5
convertase) by greater than 50 (e.g., greater than 55, 60, 65, 70,
75, 80, 85, 90, or 95 or more) %. Methods for determining whether
an antibody can block the generation or activity of the C5a and/or
C5b active fragments of a complement component C5 protein, or
binding to complement component C4b or C3b, are known in the art
and described in, e.g., U.S. Pat. No. 6,355,245 and Wurzner et al.
(1991) Complement Inflamm 8:328-340. (See also below.)
[0117] In some embodiments, an anti-C5 antibody binds to an
amino-terminal region of the alpha chain of a complement component
C5 protein, but does not bind to free C5a. Epitopes for an anti-C5
antibody within the amino-terminal region of the alpha chain
include, e.g., epitopes within the human sequence
VIDHQGTKSSKCVRQKVEGSS (SEQ ID NO:5).
[0118] In some embodiments, the composition comprises, and/or the
antibody is, eculizumab (Soliris.RTM.; Alexion Pharmaceuticals,
Inc., Cheshire, Conn.). (See, e.g., Kaplan (2002) Curr Opin
Investig Drugs 3(7): 1017-23; Hill (2005) Clin Adv Hematol Oncol
3(11):849-50; and Rother et al. (2007) Nature Biotechnology 25(11):
1256-1488.)
[0119] In some embodiments, the composition comprises, and/or the
antibody is, pexelizumab (Alexion Pharmaceuticals, Inc., Cheshire,
Conn.). (See, e.g., Whiss (2002) Curr Opin Investig Drugs
3(6):870-7; Patel et al. (2005) Drugs Today (Barc) 41(3): 165-70;
and Thomas et al. (1996) Mol Immunol. 33(17-18): 1389-401.)
[0120] In some embodiments, the C5 inhibitor is an antibody that
binds to C5a (sometimes referred to herein as "an anti-C5a
antibody"). In some embodiments, the antibody binds to C5a, but not
to full-length C5. As discussed above, the proform of C5, a 1676
amino acid residue precursor protein, is processed by a series of
proteolytic cleavage events. The first 18 peptides (numbered -18 to
-1) constitute a signal peptide that is cleaved from the precursor
protein. The remaining 1658 amino acid protein is cleaved in two
places to form the alpha and beta chains. The first cleavage event
occurs between amino acid residues 655 and 656. The second cleavage
occurs between amino acid residues 659 to 660. The two cleavage
events result in the formation of three distinct polypeptide
fragments: (i) a fragment comprising amino acids 1 to 655, which is
referred to as the beta chain; (ii) a fragment comprising amino
acids 660 to 1658, which is referred to as the alpha chain; and
(iii) a tetrapeptide fragment consisting of amino acids 656 to 659.
The alpha chain and the beta chain polypeptide fragments are
connected to each other via disulfide bond and constitute the
mature C5 protein. The CP or AP C5 convertase activates mature C5
by cleaving the alpha chain between residues 733 and 734, which
results in the liberation of C5a fragment (amino acids 660 to 733).
The remaining portion of mature C5 is fragment C5b, which contains
the residues 734 to 1658 of the alpha chain disulfide bonded to the
beta chain.
[0121] In vivo, C5a is rapidly metabolized by a serum enzyme,
carboxypeptidase B, to a 73 amino acid form termed "C5a des-Arg,"
which has lost the carboxyterminal arginine residue. Accordingly,
in some embodiments, an antibody that binds to C5a also binds to
desarginated C5a. In some embodiments, an antibody that binds to
C5a does not bind to desarginated C5a.
[0122] In some embodiments, the C5 inhibitor is an antibody that
binds to a neoepitope present in C5a, i.e., an epitope that becomes
exposed upon the liberation of C5a from the alpha chain fragment of
mature C5. Antibodies that bind to C5a (e.g., a neo-epitope present
in C5a) are known in the art as are methods for producing such
antibodies. For example, an antibody that binds to C5a can have the
binding specificity of a C5a neoepitope specific antibody described
in any one of, e.g., PCT Publication No. WO 01/15731; Ames et al.
(1994) J Immunol 152(9):4572-4581; Inoue (1989) Complement Inflamm
6(3):219-222; and U.S. Pat. No. 6,866,845. In another example, an
antibody that binds to C5a can have the binding specificity of a
commercial C5a neoepitope-specific antibody such as, but not
limited to, sc-52633 (Santa Cruz Biotechnology, Inc., Santa Cruz,
Calif.), I52-1486 (BD Pharmingen/BD Biosciences), ab11877 (Abcam,
Cambridge, Mass.), and HM2079 (clone 2952; HyCult Biotechnology,
the Netherlands). In some embodiments, an antibody that binds to
C5a can crossblock the binding of any of the aforementioned C5a
neoepitope-specific antibodies.
[0123] In some embodiments, the C5 inhibitor can be an antibody
that binds to a mammalian (e.g., human) C5a protein. For example,
the antibody can bind to a human C5a protein having the following
amino acid sequence:
TLQKKIEEIAAKYKHSVVKKCCYDGACVNNDETCEQRAARISLGPRCIKAFTE
CCVVASQLRANISHKDMQLGR (SEQ ID NO: 12). The antibody can bind to
human C5a at an epitope within or overlapping with the amino acid
sequence: CCYDGACVNNDETCEQRAAR (SEQ ID NO: 13); KCCYDGACVNNDETCEQR
(SEQ ID NO:14); VNNDETCEQR (SEQ ID NO:15); VNNDET (SEQ ID NO:16);
AARISLGPR (SEQ ID NO: 17); CCYDGACVNNDETCEQRAA (SEQ ID NO: 18):
CCYDGACVNNDETCEQRA (SEQ ID NO: 19); CCYDGACVNNDETCEQR (SEQ ID
NO:20); CCYDGACVNNDETCEQ (SEQ ID NO:21); CCYDGACVNNDETCE (SEQ ID
NO:22); CYDGACVNNDETCEQRAAR (SEQ ID NO:23); YDGACVNNDETCEQRAAR (SEQ
ID NO:24); or CYDGACVNNDETCEQRAAR (SEQ ID NO:25). In some
embodiments, an antibody can bind to a human C5a protein or
fragment thereof containing an amino acid sequence that contains,
or consists of, at least four (e.g., at least four, five, six,
seven, eight, nine, 10, 11, 12, 13, 14, 15, 16, or 17 or more)
consecutive amino acids depicted in any one of SEQ ID NOs: 12-25.
Additional C5a protein fragments to which an antibody described
herein can bind and methods for generating suitable C5a-specific
antigen combining sites are set forth in, e.g., U.S. Pat. No.
4,686,100, the disclosure of which is incorporated herein by
reference in its entirety.
[0124] In some embodiments, the binding of an antibody to C5a can
inhibit the biological activity of C5a. Methods for measuring C5a
activity include, e.g., chemotaxis assays, RIAs, or ELISAs (see,
e.g., Ward and Zvaifler (1971) J Clin Invest 50(3:606-16 and
Wurzner et al. (1991) Complement Inflamm 8:328-340). In some
embodiments, the binding of an antibody to C5a can inhibit the
interaction between C5a and C5aR1. Suitable methods for detecting
and/or measuring the interaction between C5a and C5aR1 (in the
presence and absence of an antibody) are known in the art and
described in, e.g., Mary and Boulay (1993) Eur J Haematol
51(5):282-287; Kaneko et al. (1995) Immunology 8(1): 149-154;
Giannini et al. (1995) J Biol Chem 270(32):19166-19172; and U.S.
Patent Application Publication No. 20060160726. For example, the
binding of detectably labeled (e.g., radioactively labeled) C5a to
C5aR1-expressing peripheral blood mononuclear cells can be
evaluated in the presence and absence of an antibody. A decrease in
the amount of detectably-labeled C5a that binds to C5aR1 in the
presence of the antibody, as compared to the amount of binding in
the absence of the antibody, is an indication that the antibody
inhibits the interaction between C5a and C5aR1. In some
embodiments, the binding of an antibody to C5a can inhibit the
interaction between C5a and C5L2 (see below). Methods for detecting
and/or measuring the interaction between C5a and C5L2 are known in
the art and described in, e.g., Ward (2009) J Mol Med 87(4):375-378
and Chen et al. (2007) Nature 446(7132):203-207 (see below).
[0125] In some embodiments, the C5 inhibitor is an antibody that
binds to C5b (sometimes referred to herein as "an anti-C5b
antibody"). In some embodiments, the antibody binds to C5b, but
does not bind to full-length C5. The structure of C5b is described
above and also detailed in, e.g., Muller-Eberhard (1985) Biochem
Soc Symp 50:235-246; Yamamoto and Gewurz (1978) J Immunol
120(6):2008-2015; and Haviland et al. (1991), supra. As described
above, C5b combines with C6, C7, and C8 to form the C5b-8 complex
at the surface of the target cell. Protein complex intermediates
formed during the series of combinations include C5b-6 (including
C5b and C6), C5b-7 (including C5b, C6, and C7), and C5b-8
(including C5b, C6, C7, and C8). Upon binding of several C9
molecules, the membrane attack complex (MAC, C5b-9 terminal
complement complex (TCC)) is formed. When sufficient numbers of
MACs insert into target cell membranes, the openings they create
(MAC pores) mediate rapid osmotic lysis of the target cells.
[0126] In some embodiments, the binding of an antibody to C5b can
inhibit the interaction between C5b and C6. In some embodiments,
the binding of the antibody to C5b can inhibit the assembly or
activity of the C5b-9 MAC-TCC. In some embodiments, the binding of
an antibody to C5b can inhibit complement-dependent cell lysis
(e.g., in vitro and/or in vivo). Suitable methods for evaluating
whether an antibody inhibits complement-dependent lysis include,
e.g., hemolytic assays or other functional assays for detecting the
activity of soluble C5b-9. For example, a reduction in the
cell-lysing ability of complement in the presence of an antibody
can be measured by a hemolysis assay described by Kabat and Mayer
(eds.), "Experimental Immunochemistry, 2.sup.nd Edition," 135-240,
Springfield, Ill., CC Thomas (1961), pages 135-139, or a
conventional variation of that assay such as the chicken
erythrocyte hemolysis method as described in, e.g., Hillmen et al.
(2004) N Engl J Med 350(6):552.
[0127] Antibodies that bind to C5b as well as methods for making
such antibodies are known in the art. See, e.g., U.S. Pat. No.
6,355,245. Commercially available anti-C5b antibodies are available
from a number of vendors including, e.g., Hycult Biotechnology
(catalogue number: HM2080: clone 568) and Abcam.TM. (ab46151 or
ab46168).
[0128] In some embodiments, the C5 inhibitor is an antibody that
binds to a mammalian (e.g., human) form of C5b. For example, the
antibody can bind to a portion of a human C5b protein having the
following amino acid sequence:
QEQTYVISAPKIFRVGASENIVIQVYGYTEAFDATISIKSYPDKKFSYSSGHVHL
SSENKFQNSAILTIQPKQLPGGQNPVSYVYLEVVSKHFSKSKRMPITYDNGFLF
IHTDKPVYTPDQSVKVRVYSLNDDLKPAKRETVLTFIDPEGSEVDMVEEIDHI
GIISFPDFKIPSNPRYGMWTIKAKYKEDFSTTGTAYFEVKEYVLPHFSVSIEPEY
NFIGYKNFKNFEITIKARYFYNKVVTEADVYITFGIREDLKDDQKEMMQTAM
QNTMLINGIAQVTFDSETAVKELSYYSLEDLNNKYLYIAVTVIESTGGFSEEAE
IPGIKYVLSPYKLNLVATPLFLKPGIPYPIKVQVKDSLDQLVGGVPVILNAQTID
VNQETSDLDPSKSVTRVDDGVASFVLNLPSGVTVLEFNVKTDAPDLPEENQA
REGYRAIAYSSLSQSYLYIDWTDNHKALLVGEHLNIIVTPKSPYIDKITHYNYL
ILSKGKIIHFGTREKFSDASYQSINIPVTQNMVPSSRLLVYYIVTGEQTAELVSD
SVWLNIEEKCGNQLQVHLSPDADAYSPGQTVSLNMATGMDSWVALAAVDS
AVYGVQRGAKKPLERVFQFLEKSDLGCGAGGGLNNANVFHLAGLTFLTNAN ADDSQENDEPCKEIL
(SEQ ID NO:4). In some embodiments, the antibody can bind to a
portion of a human C5b protein having the following amino acid
sequence: LHMKTLLPVSKPEIRSYFPESWLWEVHLVPRRKQLQFALPDSLTTWEIQGIGIS
NTGICVADTVKAKVFKDVFLEMNIPYSVVRGEQIQLKGTVYNYRTSGMQFCV
KMSAVEGICTSESPVIDHQGTKSSKCVRQKVEGSSSHLVTFTVLPLEIGLHNIN
FSLETWFGKEILVKTLRVVPEGVKRESYSGVTLDPRGIYGTISRRKEFPYRIPL
DLVPKTEIKRILSVKGLLVGEILSAVLSQEGINILTHLPKGSAEAELMSVVPVFY
VFHYLETGNHWNIFHSDPLIEKQKLKKKLKEGMLSIMSYRNADYSYSVWKG
GSASTWLTAFALRVLGQVNKYVEQNQNSICNSLLWLVENYQLDNGSFKENS
QYQPIKLQGTLPVEARENSLYLTAFTVIGIRKAFDICPLVKIDTALIKADNFLLE
NTLPAQSTFTLAISAYALSLGDKTHPQFRSIVSALKREALVKGNPPIYRFWKD
NLQHKDSSVPNTGTARMVETTAYALLTSLNLKDINYVNPVIKWLSEEQRYGG
GFYSTQDTINAIEGLTEYSLLVKQLRLSMDIDVSYKHKGALHNYKMTDKNFL
GRPVEVLLNDDLIVSTGFGSGLATVHVTTVVHKTSTSEEVCSFYLKIDTQDIEA
SHYRGYGNSDYKRIVACASYKPSREESSSGSSHAVMDISLPTGISANEEDLKA
LVEGVDQLFTDYQIKDGHVILQLNSIPSS
DFLCVRFRIFELFEVGFLSPATFTVYEYHRPDKQCTMFYSTSNIKIQKVCEGAA
CKCVEADCGQMQEELDLTISAETRKQTACKPEIAYAYKVSITSITVENVFVKY
KATLLDIYKTGEAVAEKDSEITFIKKVTCTNAELVKGRQYLIMGKEALQIKYN
FSFRYIYPLDSLTWIEYWPRDTTCSSCQAFLANLDEFAEDIFLNGC (SEQ ID NO:26). In
some embodiments, the antibody can bind to human C5b protein or
fragment thereof containing an amino acid sequence that contains,
or consists of, at least four (e.g., at least four, five, six,
seven, eight, nine, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20
or more) consecutive amino acids depicted in SEQ ID NO:4 or SEQ ID
NO:26.
[0129] Additional exemplary sub-fragments of human C5b or C5a to
which a C5 inhibitor antibody can bind are disclosed in, e.g., U.S.
Pat. No. 6,355,245, the disclosure of which is incorporated herein
by reference.
[0130] In some embodiments, the inhibitor is an antibody that
specifically binds to a C5a polypeptide (e.g., the human C5a
polypeptide having the amino acid sequence depicted in SEQ ID
NO:12). In some embodiments, the inhibitor is an antibody that
specifically binds to a C5b polypeptide.
[0131] Methods for determining whether a particular agent is an
inhibitor of human complement component C5 are described herein and
are known in the art. For example, the concentration and/or
physiologic activity of C5a and C5b in a body fluid can be measured
by methods well known in the art. Methods for measuring C5a
concentration or activity include, e.g., chemotaxis assays, RIAs,
or ELISAs (see, e.g., Ward and Zvaifler (1971) J Clin Invest.
50(3):606-16 and Wurzner et al. (1991) Complement Inflamm.
8:328-340). For C5b, hemolytic assays or assays for soluble C5b-9
as discussed herein can be used. Other assays known in the art can
also be used. Using assays of these or other suitable types,
candidate agents capable of inhibiting human complement component
C5 such as an anti-C5 antibody, can be screened in order to, e.g.,
identify compounds that are useful in the methods described herein
and determine the appropriate dosage levels of such compounds.
[0132] Methods for detecting inhibition of expression of mRNA or
protein (e.g., inhibition of human C5 protein expression or
expression of an mRNA encoding human C5 protein) are well known in
the art of molecular biology and include, e.g., Northern blot and
RT-PCR (or quantitative RT-PCR) techniques for mRNA and for protein
detection, Western blot, dot blot, or ELISA techniques. (See, e.g.,
Sambrook et al. (1989) "Molecular Cloning: A Laboratory Manual,
2.sup.nd Edition," Cold Spring Harbor Laboratory Press, Cold Spring
Harbor, N.Y.)
[0133] Methods for determining whether a candidate compound
inhibits the cleavage of human C5 into forms C5a and C5b are known
in the art and described in, e.g., Moongkarndi et al. (1982)
Immunobiol. 162:397; Moongkarndi et al. (1983) Immunobiol. 165:323;
Isenman et al. (1980) J Immunol. 124(1):326-31; Thomas et al.
(1996) Mol. Immunol. 33(17-18):1389-401; and Evans et al. (1995)
Mol. Immunol. 32(16): 1183-95.
[0134] Inhibition of human complement component C5 can also reduce
the cell-lysing ability of complement in a subject's body fluids.
Such reductions of the cell-lysing ability of complement present
can be measured by methods well known in the art such as, for
example, by a conventional hemolytic assay such as the hemolysis
assay described by Kabat and Mayer (eds), "Experimental
Immunochemistry, 2.sup.nd Edition," 135-240, Springfield, Ill., CC
Thomas (1961), pages 135-139, or a conventional variation of that
assay such as the chicken erythrocyte hemolysis method as described
in, e.g., Hillmen et al. (2004) N Engl J Med 350(6):552.
[0135] Pharmaceutical Compositions and Formulations.
[0136] The compositions containing a complement inhibitor (e.g., an
inhibitor of human complement component C5 such as an anti-C5
antibody or antigen-binding fragment thereof) can be formulated as
a pharmaceutical composition, e.g., for administration to a subject
to treat aHUS, CAPS, Degos disease, or TMA. The pharmaceutical
compositions will generally include a pharmaceutically acceptable
carrier. As used herein, a "pharmaceutically acceptable carrier"
refers to, and includes, any and all solvents, dispersion media,
coatings, antibacterial and antifungal agents, isotonic and
absorption delaying agents, and the like that are physiologically
compatible. The compositions can include a pharmaceutically
acceptable salt, e.g., an acid addition salt or a base addition
salt (see e.g., Berge et al. (1977). J. Pharm. Sci. 66:1-19).
[0137] The compositions can be formulated according to standard
methods. Pharmaceutical formulation is a well-established art, and
is further described in, e.g., Gennaro (2000) "Remington: The
Science and Practice of Pharmacy," 20.sup.th Edition, Lippincott,
Williams & Wilkins (ISBN: 0683306472); Ansel et al. (1999)
"Pharmaceutical Dosage Forms and Drug Delivery Systems," 7.sup.th
Edition, Lippincott Williams & Wilkins Publishers (ISBN:
0683305727); and Kibbe (200(1)) "Handbook of Pharmaceutical
Excipients American Pharmaceutical Association." 3.sup.rd Edition
(ISBN: 091733096X). In some embodiments, a composition can be
formulated, for example, as a buffered solution at a suitable
concentration and suitable for storage at 2-8.degree. C. In some
embodiments, a composition can be formulated for storage at a
temperature below 0.degree. C. (e.g., -20.degree. C. or -80.degree.
C.).
[0138] The pharmaceutical compositions can be in a variety of
forms. These forms include, e.g., 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,
in part, on the intended mode of administration and therapeutic
application. For example, compositions containing an anti-C5
antibody intended for systemic or local delivery can be in the form
of injectable or infusible solutions. Accordingly, the compositions
can be formulated for administration by a parenteral mode (e.g.,
intravenous, subcutaneous, intraperitoneal, or intramuscular
injection). "Parenteral administration," "administered
parenterally," and other grammatically equivalent phrases, as used
herein, refer to modes of administration other than enteral and
topical administration, usually by injection, and include, without
limitation, intravenous, intranasal, intraocular, pulmonary,
intramuscular, intraarterial, intrathecal, intracapsular,
intraorbital, intracardiac, intradermal, intrapulmonary,
intraperitoneal, transtracheal, subcutaneous, subcuticular,
intraarticular, subcapsular, subarachnoid, intraspinal, epidural,
intracerebral, intracranial, intracarotid and intrasternal
injection and infusion (see below).
[0139] The compositions can be formulated as a solution,
microemulsion, dispersion, liposome, or other ordered structure
suitable for stable storage at high concentration. Sterile
injectable solutions can be prepared by incorporating an antibody
described herein 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 an inhibitor of human
complement component C5 (e.g., an anti-C5 antibody) described
herein 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, methods for preparation include
vacuum drying and freeze-drying that yield a powder of the antibody
described herein 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 a reagent that delays
absorption, for example, monostearate salts and gelatin.
[0140] In certain embodiments, the C5 inhibitor (e.g., an anti-C5
antibody or antigen-binding fragment thereof) can be prepared with
a carrier that will protect the compound against rapid release,
such as a controlled release formulation, including implants 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 known in the art. (See, e.g., J. R. Robinson
(1978) "Sustained and Controlled Release Drug Delivery Systems,"
Marcel Dekker, Inc., New York.)
[0141] In some embodiments, an antibody described herein can be
formulated in a composition suitable for intrapulmonary
administration (e.g., for administration via nebulizer) to a mammal
such as a human. Methods for preparing such compositions are well
known in the art and described in, e.g., U.S. Patent Application
Publication No. 20080202513; U.S. Pat. Nos. 7,112,341 and
6,019,968; and PCT Publication Nos. WO 00/061178 and WO 06/122257,
the disclosures of each of which are incorporated herein by
reference in their entirety. Dry powder inhaler formulations and
suitable systems for administration of the formulations are
described in, e.g., U.S. Patent Application Publication No.
20070235029, PCT Publication No. WO 00/69887; and U.S. Pat. No.
5,997,848.
[0142] In some embodiments, an inhibitor of human C5 (e.g., an
anti-C5 antibody or antigen-binding fragment thereof) described
herein can be modified, e.g., with a moiety that improves its
stabilization and/or retention in circulation, e.g., in blood,
serum, or other tissues. The stabilization moiety can improve the
stability, or retention of, the antibody by at least 1.5 (e.g., at
least 2, 5, 10, 15, 20, 25, 30, 40, or 50 or more) fold.
[0143] The nucleic acid inhibitors of human complement component C5
described herein (e.g., an anti-sense nucleic acid or siRNA) can be
incorporated into a gene construct to be used as a part of a gene
therapy protocol to deliver nucleic acids that can be used to
express and produce agents within cells. Expression constructs of
such components may be administered in any biologically effective
carrier, e.g. any formulation or composition capable of effectively
delivering the component gene to cells in vivo. Approaches include
insertion of the subject gene in viral vectors including
recombinant retroviruses, adenovirus, adeno-associated virus,
lentivirus, and herpes simplex virus-1 (HSV-1), or recombinant
bacterial or eukaryotic plasmids. Viral vectors can transfect cells
directly; plasmid DNA can be delivered with the help of, for
example, cationic liposomes (lipofectin) or derivatized (e.g.,
antibody conjugated), polylysine conjugates, gramicidin S,
artificial viral envelopes or other such intracellular carriers, as
well as direct injection of the gene construct or CaPO.sub.4
precipitation carried out in vivo. (See also, "Ex vivo Approaches,"
below.) Examples of suitable retroviruses include pLJ, pZIP, pWE
and pEM which are known to those skilled in the art (see, e.g.,
Eglitis et al. (1985) Science 230:1395-1398; Danos and Mulligan
(1988) Proc. Natl. Acad. Sci. USA 85:6460-6464; Wilson et al.
(1988) Proc. Natl. Acad Sci. USA 85:3014-3018; Armentano et al.
(1990) Proc. Natl. Acad. Sci. USA 87:6141-6145; Huber et al. (1991)
Proc. Natl. Acad. Sci. USA 88:8039-8043; Ferry et al. (1991) Proc.
Natl. Acad. Sci. USA 88:8377-8381; Chowdhury et al. (1991) Science
254:1802-1805; van Beusechem et al. (1992) Proc. Natl. Acad. Sci.
USA 89:7640-7644; Kay et al. (1992) Human Gene Therapy 3:641-647;
Dai et al. (1992) Proc. Natl. Acad. Sci. USA 89:10892-10895; Hwu et
al. (1993) J. Immunol. 150:4104-4115; U.S. Pat. Nos. 4,868,116 and
4,980,286; PCT Publication Nos. WO89/07136, WO89/02468, WO89/05345,
and WO92/07573). Another viral gene delivery system utilizes
adenovirus-derived vectors (see, e.g., Berkner et al. (1988)
BioTechniques 6:616; Rosenfeld et al. (1991) Science 252:431-434;
and Rosenfeld et al. (1992) Cell 68:143-155). Suitable adenoviral
vectors derived from the adenovirus rain Ad type 5 dl324 or other
strains of adenovirus (e.g., Ad2, Ad3, Ad7, etc.) are known to
those skilled in the art. Yet another viral vector system useful
for delivery of the subject gene is the adeno-associated virus
(AAV). See, e.g., Flotte et al. (1992) Am. J. Respir. Cell. Mol.
Biol. 7:349-356; Samulski et al. (1989) J. Virol. 6:3822-3828; and
McLaughlin et al. (1989) J. Virol 62: 1963-1973.
[0144] In some embodiments, more than one (e.g., two, three, four,
five, six, seven, eight, nine, or 10 or more) inhibitor(s) (e.g.,
one or more inhibitors of human C5) can be co-formulated. For
example, a C5-specific siRNA and an anti-C5 antibody can be
formulated together.
[0145] In some embodiments, an inhibitor of human complement (e.g.,
an inhibitor human C5 such as an anti-C5 antibody or
antigen-binding fragment thereof) described herein can be
formulated with one or more additional active agents useful for
treating a complement-associated disorder (e.g., any of the
complement-associated disorders described herein such as APS, CAPS,
aHUS, Degos disease, HELLP syndrome) or ameliorating a symptom
thereof. For example, an anti-C5 antibody can be formulated with an
antihypertensive, an anticoagulant, and/or a steroid (e.g., a
corticosteroid). Examples of anticoagulants include, e.g., warfarin
(Coumadin), aspirin, heparin, phenindione, fondaparinux,
idraparinux, and thrombin inhibitors (e.g., argatroban, lepirudin,
bivalirudin, or dabigatran). An inhibitor of human C5 (e.g., an
anti-C5 antibody, an anti-C5a antibody, or an anti-C5b antibody)
can also be formulated with a fibrinolytic agent (e.g., ancrod,
.epsilon.-aminocaproic acid, antiplasmin-al, prostacyclin, and
defibrotide), cyclophosphamide, or an anti-cytokine agent for the
treatment of CAPS. Anti-cytokine agents include, e.g., antibodies
or soluble receptors that bind to and modulate the activity of
cytokine (e.g., a pro-inflammatory cytokine such as TNF). Examples
of anti-cytokine agents include, e.g., a TNF inhibitor such as a
soluble TNF receptor (e.g., etanercept; Enbrel.RTM.) or an anti-TNF
antibody (e.g., infliximab; Remicade.RTM.). In some embodiments,
the inhibitor can be formulated with, or for use with, an anti-CD20
agent such as rituximab (Rituxan.TM.; Biogen Idec, Cambridge,
Mass.). In some embodiments, the inhibitor of human C5 can be
formulated for administration to a subject along with intravenous
immunoglobulin therapy (IVIG) or with plasma exchange.
[0146] When the inhibitor of human C5 is to be used in combination
with a second active agent, or when two or more inhibitors of human
C5 are to be used (e.g., an anti-C5a antibody and an anti-C5b
antibody), the agents can be formulated separately or together. For
example, the respective pharmaceutical compositions can be mixed,
e.g., just prior to administration, and administered together or
can be administered separately, e.g., at the same or different
times (see below).
[0147] As described above, a composition can be formulated such
that it includes a therapeutically effective amount of an inhibitor
of human C5 (e.g., an anti-C5 antibody or antigen-binding fragment
thereof) or the composition can be formulated to include a
sub-therapeutic amount of the inhibitor and a sub-therapeutic
amount of one or more additional active agents such that the
components in total are therapeutically effective for treating a
complement-associated disorder such as any of those described
herein. In some embodiments, a composition can be formulated to
include two or more inhibitors of human C5, each at sub-therapeutic
doses, such that the inhibitors in total are at a concentration
that is therapeutically effective for treating a
complement-associated disorder such as, e.g., aHUS, CAPS, Degos
disease, or HELLP syndrome. Methods for determining a
therapeutically effective dose (e.g., a therapeutically effective
dose of an anti-C5 antibody) are known in the art and described
herein.
Methods for Producing an Antibody
[0148] Suitable methods for producing an antibody (e.g., an anti-C5
antibody, an anti-C5a antibody, and/or an anti-C5b antibody), or
antigen-binding fragments thereof, in accordance with the
disclosure are known in the art (see, e.g., U.S. Pat. No.
6,355,245) and described herein. For example, monoclonal anti-C5
antibodies may be generated using complement component
C5-expressing cells, a C5 polypeptide, or an antigenic fragment of
C5 polypeptide (e.g., C5a or C5b), as an immunogen, thus raising an
immune response in animals from which antibody-producing cells and
in turn monoclonal antibodies may be isolated. The sequence of such
antibodies may be determined and the antibodies or variants thereof
produced by recombinant techniques. Recombinant techniques may be
used to produce chimeric, CDR-grafted, humanized and fully human
antibodies based on the sequence of the monoclonal antibodies as
well as polypeptides capable of binding to human complement
component C5.
[0149] Moreover, antibodies derived from recombinant libraries
("phage antibodies") may be selected using, e.g., C5-expressing
cells, or polypeptides derived therefrom, as bait to isolate the
antibodies or polypeptides on the basis of target specificity. The
production and isolation of non-human and chimeric anti-C5
antibodies are well within the purview of the skilled artisan.
[0150] Recombinant DNA technology can be used to modify one or more
characteristics of the antibodies produced in non-human cells.
Thus, chimeric antibodies can be constructed in order to decrease
the immunogenicity thereof in diagnostic or therapeutic
applications. Moreover, immunogenicity can be minimized by
humanizing the antibodies by CDR grafting and, optionally,
framework modification. See, U.S. Pat. Nos. 5,225,539 and
7,393,648, the contents of each of which are incorporated herein by
reference.
[0151] Antibodies can be obtained from animal serum or, in the case
of monoclonal antibodies or fragments thereof, produced in cell
culture. Recombinant DNA technology can be used to produce the
antibodies according to established procedure, including procedures
in bacterial or preferably mammalian cell culture. The selected
cell culture system preferably secretes the antibody product.
[0152] In another embodiment, a process for the production of an
antibody disclosed herein includes culturing a host, e.g., E. coli
or a mammalian cell, which has been transformed with a hybrid
vector. The vector includes one or more expression cassettes
containing a promoter operably linked to a first DNA sequence
encoding a signal peptide linked in the proper reading frame to a
second DNA sequence encoding the antibody protein. The antibody
protein is then collected and isolated. Optionally, the expression
cassette may include a promoter operably linked to polycistronic
(e.g., bicistronic) DNA sequences encoding antibody proteins each
individually operably linked to a signal peptide in the proper
reading frame.
[0153] Multiplication of hybridoma cells or mammalian host cells in
vitro is carried out in suitable culture media, which include the
customary standard culture media (such as, for example Dulbecco's
Modified Eagle Medium (DMEM) or RPMI 1640 medium), optionally
replenished by a mammalian serum (e.g. fetal calf serum), or trace
elements and growth sustaining supplements (e.g. feeder cells such
as normal mouse peritoneal exudate cells, spleen cells, bone marrow
macrophages, 2-aminoethanol, insulin, transferrin, low density
lipoprotein, oleic acid, or the like). Multiplication of host cells
which are bacterial cells or yeast cells is likewise carried out in
suitable culture media known in the art. For example, for bacteria
suitable culture media include medium LE, NZCYM, NZYM, NZM,
Terrific Broth, SOB, SOC, 2xYT, or M9 Minimal Medium. For yeast,
suitable culture media include medium YPD, YEPD, Minimal Medium, or
Complete Minimal Dropout Medium.
[0154] In vitro production provides relatively pure antibody
preparations and allows scale-up production to give large amounts
of the desired antibodies. Techniques for bacterial cell, yeast,
plant, or mammalian cell cultivation are known in the art and
include homogeneous suspension culture (e.g. in an airlift reactor
or in a continuous stirrer reactor), and immobilized or entrapped
cell culture (e.g. in hollow fibers, microcapsules, on agarose
microbeads or ceramic cartridges).
[0155] Large quantities of the desired antibodies can also be
obtained by multiplying mammalian cells in vivo. For this purpose,
hybridoma cells producing the desired antibodies are injected into
histocompatible mammals to cause growth of antibody-producing
tumors. Optionally, the animals are primed with a hydrocarbon,
especially mineral oils such as pristane (tetramethyl-pentadecane),
prior to the injection. After one to three weeks, the antibodies
are isolated from the body fluids of those mammals. For example,
hybridoma cells obtained by fusion of suitable myeloma cells with
antibody-producing spleen cells from Balb/c mice, or transfected
cells derived from hybridoma cell line Sp2/0 that produce the
desired antibodies are injected intraperitoneally into Balb/c mice
optionally pre-treated with pristane. After one to two weeks,
ascitic fluid is taken from the animals.
[0156] The foregoing, and other, techniques are discussed in, for
example, Kohler and Milstein, (1975) Nature 256:495-497; U.S. Pat.
No. 4,376,110; Harlow and Lane, Antibodies: a Laboratory Manual,
(1988) Cold Spring Harbor, the disclosures of which are all
incorporated herein by reference. Techniques for the preparation of
recombinant antibody molecules are described in the above
references and also in, e.g. WO97/08320; U.S. Pat. No. 5,427,908;
U.S. Pat. No. 5,508,717; Smith (1985) Science 225:1315-1317;
Parmley and Smith (1988) Gene 73:305-318; De La Cruz et al. (1988)
Journal of Biological Chemistry 263:4318-4322; U.S. Pat. No.
5,403,484; U.S. Pat. No. 5,223,409; WO88/06630; WO92/15679; U.S.
Pat. No. 5,780,279; U.S. Pat. No. 5,571,698; U.S. Pat. No.
6,040,136; Davis et al. (1999) Cancer Metastasis Rev. 18(4):421-5;
and Taylor et al. (1992) Nucleic Acids Research 20: 6287-6295;
Tomizuka et al. (2000) Proc. Natl. Acad Sci. USA 97(2): 722-727,
the contents of each of which are incorporated herein by reference
in their entirety.
[0157] The cell culture supernatants are screened for the desired
antibodies, preferentially by immunofluorescent staining of
complement component C5-expressing cells, by immunoblotting, by an
enzyme immunoassay, e.g. a sandwich assay or a dot-assay, or a
radioimmunoassay.
[0158] For isolation of the antibodies, the immunoglobulins in the
culture supernatants or in the ascitic fluid ma) be concentrated,
e.g., by precipitation with ammonium sulfate, dialysis against
hygroscopic material such as polyethylene glycol, filtration
through selective membranes, or the like. If necessary and/or
desired, the antibodies are purified by the customary
chromatography methods, for example gel filtration, ion-exchange
chromatography, chromatography over DEAE-cellulose and/or (immuno-)
affinity chromatography, e.g. affinity chromatography with one or
more surface polypeptides derived from a complement component
C5-expressing cell line, or with Protein-A or -G.
[0159] Another embodiment provides a process for the preparation of
a bacterial cell line secreting antibodies directed against a C5
protein in a suitable mammal. For example a rabbit is immunized
with pooled samples from C5-expressing tissue or cells or C5
polypeptide or fragments thereof. A phage display library produced
from the immunized rabbit is constructed and panned for the desired
antibodies in accordance with methods well known in the art (such
as, e.g., the methods disclosed in the various references
incorporated herein by reference).
[0160] Hybridoma cells secreting the monoclonal antibodies are also
disclosed. The preferred hybridoma cells are genetically stable,
secrete monoclonal antibodies described herein of the desired
specificity, and can be expanded from deep-frozen cultures by
thawing and propagation in vitro or as ascites in vivo.
[0161] In another embodiment, a process is provided for the
preparation of a hybridoma cell line secreting monoclonal
antibodies against a complement component C5 protein. In that
process, a suitable mammal, for example a Balb/c mouse, is
immunized with one or more polypeptides or antigenic fragments of
C5 or with one or more polypeptides or antigenic fragments derived
from a C5-expressing cell, the C5-expressing cell itself, or an
antigenic carrier containing a purified polypeptide as described.
Antibody-producing cells of the immunized mammal are grown briefly
in culture or fused with cells of a suitable myeloma cell line. The
hybrid cells obtained in the fusion are cloned, and cell clones
secreting the desired antibodies are selected. For example, spleen
cells of Balb/c mice immunized with a C5-expressing Chronic
Lymphocytic Leukemia (CLL) cell line are fused with cells of the
myeloma cell line PAI or the myeloma cell line Sp2/0-Ag 14. The
obtained hybrid cells are then screened for secretion of the
desired antibodies and positive hybridoma cells are cloned.
[0162] Methods for preparing a hybridoma cell line include
immunizing Balb/c mice by injecting subcutaneously and/or
intraperitoneally an immunogenic composition containing human C5
protein (or an immunogenic fragment thereof) several times, e.g.,
four to six times, over several months, e.g., between two and four
months. Spleen cells from the immunized mice are taken two to four
days after the last injection and fused with cells of the myeloma
cell line PAI in the presence of a fusion promoter, preferably
polyethylene glycol. Preferably, the myeloma cells are fused with a
three- to twenty-fold excess of spleen cells from the immunized
mice in a solution containing about 30% to about 50% polyethylene
glycol of a molecular weight around 4000. After the fusion, the
cells are expanded in suitable culture media as described supra,
supplemented with a selection medium, for example HAT medium, at
regular intervals in order to prevent normal myeloma cells from
overgrowing the desired hybridoma cells.
[0163] The antibodies and fragments thereof can be "chimeric."
Chimeric antibodies and antigen-binding fragments thereof comprise
portions from two or more different species (e.g., mouse and
human). Chimeric antibodies can be produced with mouse variable
regions of desired specificity spliced onto human constant domain
gene segments (for example, U.S. Pat. No. 4,816,567). In this
manner, non-human antibodies can be modified to make them more
suitable for human clinical application (e.g., methods for treating
or preventing a complement associated disorder in a human
subject).
[0164] The monoclonal antibodies of the present disclosure include
"humanized" forms of the non-human (e.g., mouse) antibodies.
Humanized or CDR-grafted mAbs are particularly useful as
therapeutic agents for humans because they are not cleared from the
circulation as rapidly as mouse antibodies and do not typically
provoke an adverse immune reaction. Methods of preparing humanized
antibodies are generally well known in the art. For example,
humanization can be essentially performed following the method of
Winter and co-workers (see, e.g., Jones et al. (1986) Nature
321:522-525; Riechmann et al. (1988) Nature 332:323-327; and
Verhoeyen et al. (1988) Science 239:1534-1536), by substituting
rodent CDRs or CDR sequences for the corresponding sequences of a
human antibody. Also see. e.g., Staelens et al. (2006) Mol Immunol
43:1243-1257. In some embodiments, humanized forms of non-human
(e.g., mouse) antibodies are human antibodies (recipient antibody)
in which hypervariable (CDR) region residues of the recipient
antibody are replaced by hypervariable region residues from a
non-human species (donor antibody) such as a mouse, rat, rabbit, or
non-human primate having the desired specificity, affinity, and
binding capacity. In some instances, framework region residues of
the human immunoglobulin are also replaced by corresponding
non-human residues (so called "back mutations"). In addition, phage
display libraries can be used to vary amino acids at chosen
positions within the antibody sequence. The properties of a
humanized antibody are also affected by the choice of the human
framework. Furthermore, humanized and chimerized antibodies can be
modified to comprise residues that are not found in the recipient
antibody or in the donor antibody in order to further improve
antibody properties, such as, for example, affinity or effector
function.
[0165] Fully human antibodies are also provided in the disclosure.
The term "human antibody" includes antibodies having variable and
constant regions (if present) derived from human germline
immunoglobulin sequences. Human antibodies can 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). However, the term "human
antibody" does not 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 (i.e.,
humanized antibodies). Fully human or human antibodies may be
derived from transgenic mice carrying human antibody genes
(carrying the variable (V), diversity (D), joining (J), and
constant (C) exons) or from human cells. For example, it is now
possible to produce transgenic animals (e.g., mice) that are
capable, upon immunization, of producing a full repertoire of human
antibodies in the absence of endogenous immunoglobulin production.
(See, e.g., Jakobovits et al. (1993) Proc. Natl. Acad. Sci. USA
90:2551; Jakobovits et al. (1993) Nature 362:255-258; Bruggemann et
al. (1993) Year in Immunol. 7:33; and Duchosal et al. (1992) Nature
355:258.) Transgenic mice strains can be engineered to contain gene
sequences from unrearranged human immunoglobulin genes. The human
sequences may code for both the heavy and light chains of human
antibodies and would function correctly in the mice, undergoing
rearrangement to provide a wide antibody repertoire similar to that
in humans. The transgenic mice can be immunized with the target
protein (e.g., a complement component C5 protein, fragments
thereof, or cells expressing C5 protein) to create a diverse array
of specific antibodies and their encoding RNA. Nucleic acids
encoding the antibody chain components of such antibodies may then
be cloned from the animal into a display vector. Typically,
separate populations of nucleic acids encoding heavy and light
chain sequences are cloned, and the separate populations then
recombined on insertion into the vector, such that any given copy
of the vector receives a random combination of a heavy and a light
chain. The vector is designed to express antibody chains so that
they can be assembled and displayed on the outer surface of a
display package containing the vector. For example, antibody chains
can be expressed as fusion proteins with a phage coat protein from
the outer surface of the phage. Thereafter, display packages can be
screened for display of antibodies binding to a target.
[0166] In addition, human antibodies can be derived from
phage-display libraries (Hoogenboom et al. (1991) J. Mol. Biol.
227:381; Marks et al. (1991) J. Mol. Biol., 222:581-597; and
Vaughan et al. (1996) Nature Biotech 14:309 (1996)). Synthetic
phage libraries can be created which use randomized combinations of
synthetic human antibody V-regions. By selection on antigen fully
human antibodies can be made in which the V-regions are very
human-like in nature. See, e.g., U.S. Pat. Nos. 6,794,132,
6,680,209, 4,634,666, and Ostberg et al. (1983), Hybridoma
2:361-367, the contents of each of which are incorporated herein by
reference in their entirety.
[0167] For the generation of human antibodies, also see Mendez et
al. (1998) Nature Genetics 15:146-156, Green and Jakobovits (1998)
J. Exp. Med. 188:483-495, the disclosures of which are hereby
incorporated by reference in their entirety. Human antibodies are
further discussed and delineated in U.S. Pat. Nos. 5,939,598;
6,673,986; 6,114,598; 6,075,181; 6,162,963; 6,150,584; 6,713,610;
and 6,657,103 as well as U.S. Patent Application Publication Nos.
2003-0229905 A1, 2004-0010810 A1, US 2004-0093622 A1, 2006-0040363
A1, 2005-0054055 A1, 2005-0076395 A1, 2005-0287630 A1. See also
International Publication Nos. WO 94/02602, WO 96/34096, and WO
98/24893, and European Patent No. EP 0 463 151 B1. The disclosures
of each of the above-cited patents, applications, and references
are hereby incorporated by reference in their entirety.
[0168] In an alternative approach, others, including GenPharm
International, Inc., have utilized a "minilocus" approach. In the
minilocus approach, an exogenous Ig locus is mimicked through the
inclusion of pieces (individual genes) from the Ig locus. Thus, one
or more V.sub.H genes, one or more D.sub.H genes, one or more
J.sub.H genes, a mu constant region, and a second constant region
(preferably a gamma constant region) are formed into a construct
for insertion into an animal. This approach is described in, e.g.,
U.S. Pat. Nos. 5,545,807; 5,545,806; 5,625,825; 5,625,126;
5,633,425; 5,661,016; 5,770,429; 5,789,650; and 5,814,318;
5,591,669; 5,612,205; 5,721,367; 5,789,215; 5,643,763; 5,569,825;
5,877,397; 6,300,129; 5,874,299; 6,255,458; and 7,041,871, the
disclosures of which are hereby incorporated by reference. See also
European Patent No. 0 546 073 B1, International Patent Publication
Nos. WO 92/03918, WO 92/22645, WO 92/22647, WO 92/22670, WO
93/12227, WO 94/00569, WO 94/25585, WO 96/14436. WO 97/13852, and
WO 98/24884, the disclosures of each of which are hereby
incorporated by reference in their entirety. See further Taylor et
al. (1992) Nucleic Acids Res. 20: 6287; Chen et al. (1993) Int.
Immunol. 5: 647; Tuaillon et al. (1993) Proc. Natl. Acad Sci. USA
90: 3720-4; Choi et al. (1993) Nature Genetics 4: 117; Lonberg et
al. (1994) Nature 368: 856-859; Taylor et al. (1994) International
Immunology 6: 579-591; Tuaillon et al. (1995) J. Immunol. 154:
6453-65; Fishwild et al. (1996) Nature Biotechnology 14: 845; and
Tuaillon et al. (2000) Eur. J. Immunol. 10: 2998-3005, the
disclosures of each of which are hereby incorporated by reference
in their entirety.
[0169] In certain embodiments, de-immunized anti-C5 antibodies or
antigen-binding fragments thereof are provided. De-immunized
antibodies or antigen-binding fragments thereof are antibodies that
have been modified so as to render the antibody or antigen-binding
fragment thereof non-immunogenic, or less immunogenic, to a given
species (e.g., to a human). De-immunization can be achieved by
modifying the antibody or antigen-binding fragment thereof
utilizing any of a variety of techniques known to those skilled in
the art (see, e.g., PCT Publication Nos. WO 04/108158 and WO
00/34317). For example, an antibody or antigen-binding fragment
thereof may be de-immunized by identifying potential T cell
epitopes and/or B cell epitopes within the amino acid sequence of
the antibody or antigen-binding fragment thereof and removing one
or more of the potential T cell epitopes and/or B cell epitopes
from the antibody or antigen-binding fragment thereof, for example,
using recombinant techniques. The modified antibody or
antigen-binding fragment thereof may then optionally be produced
and tested to identify antibodies or antigen-binding fragments
thereof that have retained one or more desired biological
activities, such as, for example, binding affinity, but have
reduced immunogenicity. Methods for identifying potential T cell
epitopes and/or B cell epitopes may be carried out using techniques
known in the art, such as, for example, computational methods (see
e.g., PCT Publication No. WO 02/069232), in vitro or in silico
techniques, and biological assays or physical methods (such as, for
example, determination of the binding of peptides to MHC molecules,
determination of the binding of peptide:MHC complexes to the T cell
receptors from the species to receive the antibody or
antigen-binding fragment thereof, testing of the protein or peptide
parts thereof using transgenic animals with the MHC molecules of
the species to receive the antibody or antigen-binding fragment
thereof, or testing with transgenic animals reconstituted with
immune system cells from the species to receive the antibody or
antigen-binding fragment thereof, etc.). In various embodiments,
the de-immunized anti-C5 antibodies described herein include
de-immunized antigen-binding fragments, Fab, Fv, scFv, Fab' and
F(ab').sub.2, monoclonal antibodies, murine antibodies, engineered
antibodies (such as, for example, chimeric, single chain,
CDR-grafted, humanized, fully human antibodies, and artificially
selected antibodies), synthetic antibodies and semi-synthetic
antibodies.
[0170] In some embodiments, a recombinant DNA comprising an insert
coding for a heavy chain variable domain and/or for a light chain
variable domain of an anti-C5 antibody or a C5 protein-expressing
cell line is produced. The term DNA includes coding single stranded
DNAs, double stranded DNAs consisting of said coding DNAs and of
complementary DNAs thereto, or these complementary (single
stranded) DNAs themselves.
[0171] Furthermore, a DNA encoding a heavy chain variable domain
and/or a light chain variable domain of anti-C5 antibodies can be
enzymatically or chemically synthesized to contain the authentic
DNA sequence coding for a heavy chain variable domain and/or for
the light chain variable domain, or a mutant thereof. A mutant of
the authentic DNA is a DNA encoding a heavy chain variable domain
and/or a light chain variable domain of the above-mentioned
antibodies in which one or more amino acids are deleted, inserted,
or exchanged with one or more other amino acids. Preferably said
modification(s) are outside the CDRs of the heavy chain variable
domain and/or of the light chain variable domain of the antibody in
humanization and expression optimization applications. The term
mutant DNA also embraces silent mutants wherein one or more
nucleotides are replaced by other nucleotides with the new codons
coding for the same amino acid(s). The term mutant sequence also
includes a degenerate sequence. Degenerate sequences are degenerate
within the meaning of the genetic code in that an unlimited number
of nucleotides are replaced by other nucleotides without resulting
in a change of the amino acid sequence originally encoded. Such
degenerate sequences may be useful due to their different
restriction sites and/or frequency of particular codons which are
preferred by the specific host, particularly E. coli, to obtain an
optimal expression of the heavy chain murine variable domain and/or
a light chain murine variable domain.
[0172] The term mutant is intended to include a DNA mutant obtained
by in vitro mutagenesis of the authentic DNA according to methods
known in the art.
[0173] For the assembly of complete tetrameric immunoglobulin
molecules and the expression of chimeric antibodies, the
recombinant DNA inserts coding for heavy and light chain variable
domains are fused with the corresponding DNAs coding for heavy and
light chain constant domains, then transferred into appropriate
host cells, for example after incorporation into hybrid
vectors.
[0174] Recombinant DNAs including an insert coding for a heavy
chain murine variable domain of an anti-C5 antibody or a
C5-expressing cell line fused to a human constant domain IgG, for
example .gamma.1, .gamma.2, .gamma.3 or .gamma.4, in particular
embodiments .gamma.1 or .gamma.4, may be used. Recombinant DNAs
including an insert coding for a light chain murine variable domain
of an antibody fused to a human constant domain .kappa. or .lamda.,
preferably .kappa., are also provided.
[0175] Another embodiment pertains to recombinant DNAs coding for a
recombinant polypeptide wherein the heavy chain variable domain and
the light chain variable domain are linked by way of a spacer
group, optionally comprising a signal sequence facilitating the
processing of the antibody in the host cell and/or a DNA sequence
encoding a peptide facilitating the purification of the antibody
and/or a cleavage site and/or a peptide spacer and/or an agent.
[0176] Accordingly, the monoclonal antibodies or antigen-binding
fragments of the disclosure can be naked antibodies or
antigen-binding fragments that are not conjugated to other agents,
for example, a therapeutic agent or detectable label.
Alternatively, the monoclonal antibody or antigen-binding fragment
can be conjugated to an agent such as, for example, a cytotoxic
agent, a small molecule, a hormone, an enzyme, a growth factor, a
cytokine, a ribozyme, a peptidomimetic, a chemical, a prodrug, a
nucleic acid molecule including coding sequences (such as
antisense, RNAi, gene-targeting constructs, etc.), or a detectable
label (e.g., an NMR or X-ray contrasting agent, fluorescent
molecule, etc.). In certain embodiments, an anti-C5 antibody or
antigen-binding fragment (e.g., Fab, Fv, single-chain scFv, Fab',
and F(ab').sub.2) is linked to a molecule that increases the
half-life of the antibody or antigen-binding fragment (see
above).
[0177] Several possible vector systems are available for the
expression of cloned heavy chain and light chain genes in mammalian
cells. One class of vectors relies upon the integration of the
desired gene sequences into the host cell genome. Cells which have
stably integrated DNA can be selected by simultaneously introducing
drug resistance genes such as E. coli gpt (Mulligan and Berg (1981)
Proc. Natl. Acad. Sci. USA, 78:2072) or Tn5 neo (Southern and Berg
(1982) Mol. Appl. Genet. 1:327). The selectable marker gene can be
either linked to the DNA gene sequences to be expressed, or
introduced into the same cell by co-transfection (Wigler et al.
(1979) Cell 16:77). A second class of vectors utilizes DNA elements
which confer autonomously replicating capabilities to an
extrachromosomal plasmid. These vectors can be derived from animal
viruses, such as bovine papillomavirus (Sarver et al. (1982) Proc.
Natl. Acad. Sci. USA, 79:7147), polyoma virus (Deans et al. (1984)
Proc. Natl. Acad. Sci. USA 81:1292), or SV40 virus (Lusky and
Botchan (1981) Nature 293:79).
[0178] Since an immunoglobulin cDNA is comprised only of sequences
representing the mature mRNA encoding an antibody protein,
additional gene expression elements regulating transcription of the
gene and processing of the RNA are required for the synthesis of
immunoglobulin mRNA. These elements may include splice signals,
transcription promoters, including inducible promoters, enhancers,
and termination signals. cDNA expression vectors incorporating such
elements include those described by Okayama and Berg (1983) Mol.
Cell Biol. 3:280; Cepko et al. (1984) Cell 7:1053; and Kaufman
(1985) Proc. Natl. Acad. Sci. USA 82:689.
[0179] As is evident from the disclosure, antibodies that binds to
human complement components (e.g., antibodies that bind to C5, C5b,
or C5a) can be used in therapies (e.g., therapies for a
complement-associated disorder), including combination therapies,
as well as in the monitoring of disease progression.
[0180] In the therapeutic embodiments of the present disclosure,
bispecific antibodies are contemplated. Bispecific antibodies are
monoclonal, preferably human or humanized, antibodies that have
binding specificities for at least two different antigens. In the
present case, one of the binding specificities is for the human
complement component C5 antigen the other one is for any other
antigen.
[0181] Methods for making bispecific antibodies are within the
purview of those skilled in the art. Traditionally, the recombinant
production of bispecific antibodies is based on the co-expression
of two immunoglobulin heavy-chain/light-chain pairs, where the two
heavy chains have different specificities (Milstein and Cuello
(1983) Nature 305:537-539). Antibody variable domains with the
desired binding specificities (antibody-antigen combining sites)
can be fused to immunoglobulin constant domain sequences. The
fusion preferably is with an immunoglobulin heavy-chain constant
domain, including at least part of the hinge, C.sub.H2, and
C.sub.H3 regions. DNAs encoding the immunoglobulin heavy-chain
fusions and, if desired, the immunoglobulin light chain, are
inserted into separate expression vectors, and are co-transfected
into a suitable host organism. For further details of illustrative
currently known methods for generating bispecific antibodies see,
e.g., Suresh et al. (1986) Methods in Enzymology 121:210; PCT
Publication No. WO 96/27011; Brennan et al. (1985) Science 229:81;
Shalaby et al., J. Exp. Med. (1992) 175:217-225; Kostelny et al.
(1992) J. Immunol. 148(5: 1547-1553; Hollinger et al. (1993) Proc.
Natl. Acad. Sci. USA 90:6444-6448; Gruber et al. (1994) J. Immunol.
152:5368; and Tutt et al. (1991) J. Immunol. 147:60. Bispecific
antibodies also include cross-linked or heteroconjugate antibodies.
Heteroconjugate antibodies may be made using any convenient
cross-linking methods. Suitable cross-linking agents are well known
in the art, and are disclosed in U.S. Pat. No. 4,676,980, along
with a number of cross-linking techniques.
[0182] Various techniques for making and isolating bispecific
antibody fragments directly from recombinant cell culture have also
been described. For example, bispecific antibodies have been
produced using leucine zippers. (See, e.g., Kostelny et al. (1992)
J. Immunol. 148(5): 1547-1553). The leucine zipper peptides from
the Fos and Jun proteins may be linked to the Fab' portions of two
different antibodies by gene fusion. The antibody homodimers may be
reduced at the hinge region to form monomers and then re-oxidized
to form the antibody heterodimers. This method can also be utilized
for the production of antibody homodimers. The "diabody" technology
described by Hollinger et al. (1993) Proc. Natl. Acad. Sci. USA
90:6444-6448 has provided an alternative mechanism for making
bispecific antibody fragments. The fragments comprise a heavy-chain
variable domain (VH) connected to a light-chain variable domain
(VL) by a linker which is too short to allow pairing between the
two domains on the same chain. Accordingly, the VH and VL domains
of one fragment are forced to pair with the complementary VL and VH
domains of another fragment, thereby forming two antigen-binding
sites. Another strategy for making bispecific antibody fragments by
the use of single-chain Fv (scFv) dimers has also been reported.
(See, e.g., Gruber et al. (1994) J. Immunol. 152:5368.)
Alternatively, the antibodies can be "linear antibodies" as
described in, e.g., Zapata et al. (1995) Protein Eng. 8(10):
1057-1062. Briefly, these antibodies comprise a pair of tandem Fd
segments (V.sub.H-C.sub.H1-V.sub.H-C.sub.H1) which form a pair of
antigen binding regions. Linear antibodies can be bispecific or
monospecific.
[0183] The disclosure also embraces variant forms of bispecific
antibodies such as the tetravalent dual variable domain
immunoglobulin (DVD-Ig) molecules described in Wu et al. (2007) Nat
Biotechnol 25(11): 1290-1297. The DVD-Ig molecules are designed
such that two different light chain variable domains (VL) from two
different parent antibodies are linked in tandem directly or via a
short linker by recombinant DNA techniques, followed by the light
chain constant domain. Methods for generating DVD-Ig molecules from
two parent antibodies are further described in, e.g., PCT
Publication Nos. WO 08/024188 and WO 07/024715, the disclosures of
each of which are incorporated herein by reference in their
entirety.
Methods for Treatment
[0184] The above-described compositions (e.g., any of the C5
inhibitors described herein or pharmaceutical compositions thereof)
are useful in, inter alia, methods for treating or preventing a
variety of complement-associated disorders (e.g., AP-associated
disorders or CP-associated disorders) in a subject. The
compositions can be administered to a subject, e.g., a human
subject, using a variety of methods that depend, in part, on the
route of administration. The route can be, e.g., intravenous
injection or infusion (IV), subcutaneous injection (SC),
intraperitoneal (IP), intrapulmonary, intraocular, or intramuscular
injection. Certain inhibitors, e.g., small molecules, can be orally
administered to a subject.
[0185] Administration can be achieved by, e.g., local infusion,
injection, or by means of an implant. The implant can be of a
porous, non-porous, or gelatinous material, including membranes,
such as sialastic membranes, or fibers. The implant can be
configured for sustained or periodic release of the composition to
the subject. (See, e.g., U.S. Patent Application Publication No.
20080241223; U.S. Pat. Nos. 5,501,856; 4,863,457; and 3,710,795;
EP488401; and EP 430539, the disclosures of each of which are
incorporated herein by reference in their entirety.) The
composition can be delivered to the subject by way of an
implantable device based on, e.g., diffusive, erodible, or
convective systems, e.g., osmotic pumps, biodegradable implants,
electrodiffusion systems, electroosmosis systems, vapor pressure
pumps, electrolytic pumps, effervescent pumps, piezoelectric pumps,
erosion-based systems, or electromechanical systems.
[0186] A suitable dose of a complement inhibitor (e.g., a C5
inhibitor such as an anti-C5 antibody) described herein, which dose
is capable of treating or preventing a complement-associated
disorder in a subject, can depend on a variety of factors
including, e.g., the age, sex, and weight of a subject to be
treated and the particular inhibitor compound used. For example, a
different dose of an anti-C5 antibody may be required to treat a
subject with RA as compared to the dose of a C5-specific siRNA
molecule that is required to treat the same subject. Other factors
affecting the dose administered to the subject include, e.g., the
type or severity of the complement-associated disorder. For
example, a subject having RA may require administration of a
different dosage of an anti-C5 antibody than a subject with AMD.
Other factors can include, e.g., other medical disorders
concurrently or previously affecting the subject, the general
health of the subject, the genetic disposition of the subject,
diet, time of administration, rate of excretion, drug combination,
and any other additional therapeutics that are administered to the
subject. It should also be understood that a specific dosage and
treatment regimen for any particular subject will depend upon the
judgment of the treating medical practitioner (e.g., doctor or
nurse).
[0187] An antibody described herein can be administered as a fixed
dose, or in a milligram per kilogram (mg/kg) dose. In some
embodiments, the dose can also be chosen to reduce or avoid
production of antibodies or other host immune responses against one
or more of the active antibodies in the composition. While in no
way intended to be limiting, exemplary dosages of an antibody
include, e.g., 1-100 .mu.g/kg, 0.5-50 .mu.g/kg, 0.1-100 .mu.g/kg,
0.5-25 .mu.g/kg, 1-20 .mu.g/kg, and 1-10 .mu.g/kg, 1-100 mg/kg,
0.5-50 mg/kg, 0.1-100 mg/kg, 0.5-25 mg/kg, 1-20 mg/kg, and 1-10
mg/kg. Exemplary dosages of an antibody described herein include,
without limitation, 0.1 .mu.g/kg, 0.5 .mu.g/kg, 1.0 .mu.g/kg, 2.0
.mu.g/kg, 4 .mu.g/kg, and 8 .mu.g/kg, 0.1 mg/kg, 0.5 mg/kg, 1.0
mg/kg, 2.0 mg/kg, 4 mg/kg, and 8 mg/kg. Further exemplary dosage
amounts and schedules are provided herein (see, e.g., Tables 1 and
2).
[0188] A pharmaceutical composition can include a therapeutically
effective amount of a complement inhibitor (e.g., a C5 inhibitor
such as an anti-C5 antibody) described herein. Such effective
amounts can be readily determined by one of ordinary skill in the
art based, in part, on the effect of the administered antibody, or
the combinatorial effect of the antibody and one or more additional
active agents, if more than one agent is used. A therapeutically
effective amount of an antibody described herein can also vary
according to factors such as the disease state, age, sex, and
weight of the individual, and the ability of the antibody (and one
or more additional active agents) to elicit a desired response in
the individual, e.g., amelioration of at least one condition
parameter, e.g., amelioration of at least one symptom of the
complement-associated disorder. For example, a therapeutically
effective amount of an antibody that binds to C5a and C5b can
inhibit (lessen the severity of or eliminate the occurrence of)
and/or prevent a particular disorder, and/or any one of the
symptoms of the particular disorder known in the art or described
herein. A therapeutically effective amount is also one in which any
toxic or detrimental effects of the composition are outweighed by
the therapeutically beneficial effects.
[0189] Suitable human doses of a C5 inhibitor (e.g., an anti-C5
antibody) described herein can further be evaluated in, e.g., Phase
I dose escalation studies. See, e.g., van Gurp et al. (2008) Am J
Transplantation 8(8):1711-1718; Hanouska et al. (2007) Clin Cancer
Res 13(2, part 1):523-531; and Hetherington et al. (2006)
Antimicrobial Agents and Chemotherapy 5010): 3499-3500.
[0190] The terms "therapeutically effective amount" or
"therapeutically effective dose," or similar terms used herein are
intended to mean an amount of an agent (e.g., a C5 inhibitor) that
will elicit the desired biological or medical response (e.g., an
improvement in one or more symptoms of a complement-associated
disorder). In some embodiments, a composition described herein
contains a therapeutically effective amount of an anti-C5 antibody.
In some embodiments, a composition described herein contains a
therapeutically effective amount of a siRNA, which specifically
binds to and promotes inactivation of C5 mRNA in a mammalian cell.
In some embodiments, a composition described herein contains a
therapeutically effective amount of an antibody, which specifically
binds to C5a. In some embodiments, the composition contains any of
the antibodies described herein and one or more (e.g., three, four,
five, six, seven, eight, nine, 10, or 11 or more) additional
therapeutic agents such that the composition as a whole is
therapeutically effective. For example, a composition can contain
an anti-C5 antibody described herein and an immunosuppressive
agent, wherein the antibody and agent are each at a concentration
that when combined are therapeutically effective for treating or
preventing a complement-associated disorder in a subject.
[0191] Toxicity and therapeutic efficacy of such compositions can
be determined by known pharmaceutical procedures in cell cultures
or experimental animals (e.g., animal models of any of the
complement-associated disorders described herein). These procedures
can be used, e.g., for determining the LD.sub.50 (the dose lethal
to 50% of the population) and the ED.sub.50 (the dose
therapeutically effective in 50% of the population). The dose ratio
between toxic and therapeutic effects is the therapeutic index and
it can be expressed as the ratio LD.sub.50/ED.sub.50. A complement
inhibitor (e.g., a C5 inhibitor such as an anti-C5 antibody, an
anti-C5a antibody, or a nucleic acid that binds to and promotes the
inactivation of C5 mRNA in a mammalian cell) that exhibits a high
therapeutic index is preferred. While compositions that exhibit
toxic side effects may be used, care should be taken to design a
delivery system that targets such compounds to the site of affected
tissue and to minimize potential damage to normal cells and,
thereby, reduce side effects.
[0192] The data obtained from the cell culture assays and animal
studies can be used in formulating a range of dosage for use in
humans. The dosage of such an inhibitor lies generally within a
range of circulating concentrations of the inhibitor that include
the ED.sub.50 with little or no toxicity. The dosage may vary
within this range depending upon the dosage form employed and the
route of administration utilized. For a C5 inhibitor (e.g., an
anti-C5 antibody or an anti-C5a antibody) used as described herein
(e.g., for treating or preventing a complement-associated
disorder), the therapeutically effective dose can be estimated
initially from cell culture assays. A dose can be formulated in
animal models to achieve a circulating plasma concentration range
that includes the IC.sub.50 (i.e., the concentration of the test
compound which achieves a half-maximal inhibition of symptoms) as
determined in cell culture. Such information can be used to more
accurately determine useful doses in humans. Levels in plasma may
be measured, for example, by high performance liquid chromatography
or by ELISA.
[0193] In some embodiments, the methods can be performed in
conjunction with other therapies for complement-associated
disorders. For example, the composition can be administered to a
subject at the same time, prior to, or after, plasmapheresis, IVIG
therapy, plasma infusion, or plasma exchange. See, e.g., Appel et
al. (2005). J Am. Soc Nephrol. 16:1392-1404. In some embodiments, a
C5 inhibitor (e.g., an anti-C5 antibody or an anti-C5a antibody)
described herein is not administered in conjunction with IVIG. In
some embodiments, the composition can be administered to a subject
at the same time, prior to, or after, a kidney transplant.
Exemplary methods for transplanting an organ (e.g., a kidney) or
tissue along with exemplary dosing schedules for an anti-C5
antibody are provided herein.
[0194] A "subject," as used herein, can be any mammal. For example,
a subject can be a human (e.g., a patient), a non-human primate
(e.g., monkey, baboon, or chimpanzee), a horse, a cow, a pig, a
sheep, a goat, a dog, a cat, a rabbit, a guinea pig, a gerbil, a
hamster, a rat, or a mouse. In some embodiments, the subject is an
infant (e.g., a human infant). In some embodiments, the subject is
a female.
[0195] As used herein, a subject "in need of prevention," "in need
of treatment," or "in need thereof." refers to one, who by the
judgment of an appropriate medical practitioner (e.g., a doctor, a
nurse, or a nurse practitioner in the case of humans; a
veterinarian in the case of non-human mammals), would reasonably
benefit from a given treatment (such as treatment with a
composition comprising a complement inhibitor (e.g., a C5 inhibitor
such as an anti-C5 antibody, an anti-C5a antibody, or a nucleic
acid (e.g., an siRNA or antisense nucleic acid) that binds to and
promotes the inactivation of a C5 mRNA in a mammalian cell).
[0196] As described above, the complement inhibitors (e.g., a C5
inhibitor such as an anti-C5 antibody) described herein can be used
to treat a variety of complement-associated disorders such as,
e.g., AP-associated disorders and/or CP-associated disorders. Such
disorders include, without limitation, rheumatoid arthritis (RA);
antiphospholipid antibody syndrome; lupus nephritis;
ischemia-reperfusion injury; atypical hemolytic uremic syndrome
(aHUS); typical or infectious hemolytic uremic syndrome (tHUS);
dense deposit disease (DDD); neuromyelitis optica (NMO); multifocal
motor neuropathy (MMN); multiple sclerosis (MS); macular
degeneration (e.g., age-related macular degeneration (AMD));
hemolysis, elevated liver enzymes, and low platelets (HELLP)
syndrome; thrombotic thrombocytopenic purpura (TTP); spontaneous
fetal loss; Pauci-immune vasculitis; epidermolysis bullosa;
recurrent fetal loss; and traumatic brain injury. (See, e.g.,
Holers (2008) Immunological Reviews 223:300-316 and Holers and
Thurman (2004) Molecular Immunology 41:147-152.) In some
embodiments, the complement-associated disorder is a
complement-associated vascular disorder such as a cardiovascular
disorder, myocarditis, a cerebrovascular disorder, a peripheral
(e.g., musculoskeletal) vascular disorder, a renovascular disorder,
a mesenteric/enteric vascular disorder, vasculitis,
Henoch-Schonlein purpura nephritis, systemic lupus
erythematosus-associated vasculitis, vasculitis associated with
rheumatoid arthritis, immune complex vasculitis, Takayasu's
disease, dilated cardiomyopathy, diabetic angiopathy. Kawasaki's
disease (arteritis), venous gas embolus (VGE), and restenosis
following stent placement, rotational atherectomy, and percutaneous
transluminal coronary angioplasty (PTCA). (See, e.g., U.S. patent
application publication no. 20070172483.) Additional
complement-associated disorders include, without limitation, MG,
CAD, dermatomyositis, Graves' disease, atherosclerosis, Alzheimer's
disease, systemic inflammatory response sepsis, septic shock,
spinal cord injury, glomerulonephritis, Hashimoto's thyroiditis,
type I diabetes, psoriasis, pemphigus, AIHA, ITP, Goodpasture
syndrome, Degos disease, antiphospholipid syndrome (APS), and
catastrophic APS (CAPS).
[0197] As used herein, a subject "at risk for developing a
complement-associated disorder" (e.g., an AP-associated disorder or
a CP-associated disorder) is a subject having one or more (e.g.,
two, three, four, five, six, seven, or eight or more) risk factors
for developing the disorder. Risk factors will vary depending on
the particular complement-associated disorder, but are well known
in the art of medicine. For example, risk factors for developing
DDD include, e.g., a predisposition to develop the condition, i.e.,
a family history of the condition or a genetic predisposition to
develop the condition such as, e.g., one or more mutations in the
gene encoding complement factor H (CFH), complement factor
H-related 5 (CFHR5), and/or complement component C3 (C3). Such
DDD-associated mutations as well as methods for determining whether
a subject carries one or more of the mutations are known in the art
and described in. e.g., Licht et al. (2006) Kidney Int. 70:42-50;
Zipfel et al. (2006) "The role of complement in
membranoproliferative glomerulonephritis," In: Complement and
Kidney Disease, Springer, Berlin, pages 199-221; Ault et al. (1997)
J Biol. Chem. 272:25168-75; Abrera-Abeleda et al. (2006) J Med.
Genet 43:582-589; Poznansky et al. (1989) J Immunol. 143:1254-1258;
Jansen et al. (1998) Kidney Int. 53:331-349; and Hegasy et al.
(2002) Am J Pathol 161:2027-2034. Thus, a human at risk for
developing DDD can be, e.g., one who has one or more DDD-associated
mutations in the gene encoding CFH or one with a family history of
developing the disease.
[0198] Risk factors for TTP are well known in the art of medicine
and include, e.g., a predisposition to develop the condition, i.e.,
a family history of the condition or a genetic predisposition to
develop the condition such as, e.g., one or more mutations in the
ADAMTS13 gene. ADAMTS13 mutations associated with TTP are reviewed
in detail in, e.g., Levy et al. (2001) Nature 413:488-494; Kokame
et al. (2004) Semin. Hematol. 41:34-40; Licht et al. (2004) Kidney
Int. 66:955-958; and Noris et al. (2005) J. Am. Soc. Nephrol.
16:1177-1183. Risk factors for TTP also include those conditions or
agents that are known to precipitate TTP, or TTP recurrence, such
as, but not limited to, cancer, bacterial infections (e.g.,
Bartonella sp. infections), viral infections (e.g., HIV and
Kaposi's sarcoma virus), pregnancy, or surgery. See, e.g., Avery et
al. (1998) American Journal of Hematology 58:148-149 and Tsai,
supra). TTP, or recurrence of TTP, has also been associated with
the use of certain therapeutic agents (drugs) including, e.g.,
ticlopidine, FK506, corticosteroids, tamoxifen, or cyclosporin A
(see, e.g., Gordon et al. (1997) Seminars in Hematology 34(2):
140-147). Hereinafter, such manifestations of TTP may be, where
appropriate, referred to as, e.g., "infection-associated TTP,"
"pregnancy-associated TTP," or "drug-associated TTP." Thus, a human
at risk for developing TTP can be, e.g., one who has one or more
TTP-associated mutations in the ADAMTS13 gene. A human at risk for
developing a recurrent form of TTP can be one, e.g., who has had
TTP and has an infection, is pregnant, or is undergoing
surgery.
[0199] Risk factors for aHUS are well known in the art of medicine
and include, e.g., a predisposition to develop the condition. i.e.,
a family history of the condition or a genetic predisposition to
develop the condition such as, e.g., one or more mutations in
complement Factor H (CFH), membrane cofactor protein (MCP; CD46),
C4b-binding protein, complement factor B (CFB), or complement
factor I (CFI). (See, e.g., Warwicker et al. (1998) Kidney Int.
53:836-844; Richards et al. (2001) Am J Hum Genet 68:485-490;
Caprioli et al. (2001) Am Soc Nephrol 12:297-307; Neuman et al.
(2003) J Med Genet 40:676-681; Richards et al. (2006) Proc Natl
Acad Sci USA 100:12966-12971; Fremeaux-Bacchi et al. (2005) J Am
Soc Nephrol 17:2017-2025; Esparza-Gordillo et al. (2005) Hum Mol
Genet 14:703-712; Goicoechea de Jorge et al. (2007) Proc Natl Acad
Sci USA 104(1):240-245; Blom et al. (2008) J Immunol.
180(9):6385-91; and Fremeaux-Bacchi et al. (2004) J Medical Genet
41:e84). (See also Kavanagh et al. (2006) supra.) Risk factors also
include, e.g., infection with Streptococcus pneumoniae, pregnancy,
cancer, exposure to anti-cancer agents (e.g., quinine, mitomycin C,
cisplatin, or bleomycin), exposure to immunotherapeutic agents
(e.g., cyclosporine. OKT3, or interferon), exposure to
anti-platelet agents (e.g., ticlopidine or clopidogrel), HIV
infection, transplantation, autoimmune disease, and combined
methylmalonic aciduria and homocystinuria (cblC). See, e.g.,
Constantinescu et al. (2004) Am J Kidney Dis 43:976-982; George
(2003) Curr Opin Hematol 10:339-344; Gottschall et al. (1994) Am J
Hematol 47:283-289; Valavaara et al. (1985) Cancer 55:47-50;
Miralbell et al. (1996) J Clin Oncol 14:579-585; Dragon-Durey et
al. (2005) J Am Soc Nephrol 16:555-63; and Becker et al. (2004)
Clin Inject Dis 39:S267-S275.
[0200] Risk factors for HELLP are well known in the art of medicine
and include, e.g., multiparous pregnancy, maternal age over 25
years, Caucasian race, the occurrence of preeclampsia or HELLP in a
previous pregnancy, and a history of poor pregnancy outcome. (See,
e.g., Sahin et al. (2001) Nagova Med J 44(3):145-152; Sullivan et
al. (1994) Am J Obstet Gynecol 171:940-943; and Padden et al.
(1999) Am Fam Physician 60(3):829-836.) For example, a pregnant,
Caucasian woman who developed preeclampsia during a first pregnancy
can be one at risk for developing HELLP syndrome during, or
following, a second pregnancy.
[0201] Risk factors for CAD are well known in the art of medicine
and include, e.g., conditions or agents that are known to
precipitate CAD, or CAD recurrence, such as, but not limited to,
neoplasms or infections (e.g., bacterial and viral infections).
Conditions known to be associated with the development of CAD
include, e.g., HIV infection (and AIDS), hepatitis C infection,
Mycoplasma pneumonia infection, Epstein-Barr virus (EBV) infection,
cytomegalovirus (CMV) infection, rubella, or infectious
mononucleosis. Neoplasms associated with CAD include, without
limitation, non-Hodgkin's lymphoma. Hereinafter, such
manifestations of CAD may be, where appropriate, referred to as,
e.g., "infection-associated CAD" or "neoplasm-associated CAD."
Thus, a human at risk for developing CAD can be, e.g., one who has
an HIV infection, rubella, or a lymphoma. See also, e.g., Gertz
(2006) Hematoloy, 1:19-23; Horwitz et al. (1977) Blood 50:195-202;
Finland and Barnes (1958) AMA Arch Intern Med 191:462-466; Wang et
al. (2004) Acta Paediatr Taiwan 45:293-295; Michaux et al. (1998)
Ann Hematol 76:201-204; and Chang et al. (2004) Cancer Genet
Cytogenet 152:66-69.
[0202] Risk factors for a thrombotic microangiopathy (TMA) are well
known in the art of medicine and include, e.g., a medical history
of aHUS, TTP, or other conditions that are associated with TMA such
as lupus, cancers, disseminating intravascular coagulation and
other coagulopathies, and pre-eclampsia. See, e.g., Copelovitch and
Kaplan (2008) Pediatr Nephrol 23(10): 1761-7.
[0203] Risk factors for PCH are well known in the art of medicine
and include, e.g., conditions or agents that are known to
precipitate PCH, or PCH recurrence, such as, but not limited to,
neoplasms, infections (e.g., bacterial and viral infections), or
certain immunizations (e.g., measles immunization). Conditions
known to be associated with the development of PCH include, e.g.,
syphilis (a Treponema palladium infection), measles, mumps,
influenza virus infection, varicella-zoster virus infection,
cytomegalovirus (CMV) infection, Epstein-Barr virus (EBV)
infection, adenovirus infection, parvovirus B19 infection,
Coxsackie A9 infection, Haemophilus influenza infection. Mycoplasma
pneumoniae infection, and Klebsiella pneumoniae infection. See,
e.g., Bunch et al. (1972) Arch Dis Child 47(252):299-300; Ziman et
al. (2004) Transfusion 44(8): 1127-1128; Sokol et al. (1984) Acta
Haematol 72(4): 245-257; Papalia et al. (2000) Br J Haematol
109(2): 328-9; Sokol et al. (1982) Acta Haematol 68(4):268-277; and
Bell et al. (1973) Transfusion 13(3):138-141. Neoplasms associated
with PCH include, without limitation, both solid and hematopoietic
neoplasms such as myelofibrosis, chronic lymphocytic leukemia
(CLL), and non-Hodgkin's lymphoma See. e.g., Sharara et al. (1994)
South Med J. 87(3):397-9; Sivakumaran et al. (1999) Br J Haematol
105(1): 278-9; Breccia et al. (2004) Eur J Haematol 73(4):304-6;
and Wynn et al. (1998) Clin Lab Haematol 20(6):373-5. Hereinafter,
such manifestations of PCH may be, where appropriate, referred to
as, e.g., "infection-associated PCH" or "neoplasm-associated PCH."
Thus, a human at risk for developing PCH can be, e.g., one who has
an EBV infection or a lymphoma.
[0204] Risk factors for MG are well known in the art of medicine
and include, e.g., a predisposition to develop the condition, i.e.,
a family history of the condition or a genetic predisposition to
develop the condition such as familial MG. For example, some HLA
types are associated with an increased risk for developing MG. Risk
factors for MG include the ingestion or exposure to certain
MG-inducing drugs such as, but not limited to, D-penicillamine.
See, e.g., Drosos et al. (1993) Clin Exp Rheumatol. 11(4):387-91
and Kaeser et al. (1984) Acta Neurol Scand Suppl. 100:39-47. As MG
can be episodic, a subject who has previously experienced one or
more symptoms of having MG can be at risk for relapse. Thus, a
human at risk for developing MG can be, e.g., one who has a family
history of MG and/or one who has ingested or been administered an
MG-inducing drug such as D-penicillamine.
[0205] As used herein, a subject "at risk for developing CAPS" is a
subject having one or more (e.g., two, three, four, five, six,
seven, or eight or more) risk factors for developing the disorder.
Approximately 60% of the incidences of CAPS are preceded by a
precipitating event such as an infection. Thus, risk factors for
CAPS include those conditions known to precipitate CAPS such as,
but not limited to, certain cancers (e.g., gastric cancer, ovarian
cancer, lymphoma, leukemia, endometrial cancer, adenocarcinoma, and
lung cancer), pregnancy, puerperium, transplantation, primary APS,
rheumatoid arthritis (RA), systemic lupus erythematosus (SLE),
surgery (e.g., eye surgery), and certain infections. Infections
include, e.g., parvovirus B19 infection and hepatitis C infection.
Hereinafter, such manifestations of CAPS may be referred to as,
e.g., "cancer-associated CAPS," "transplantation-associated CAPS,"
"RA-associated CAPS," "infection-associated CAPS." or
"SLE-associated CAPS." See. e.g., Soltesz et al. (2000)
Haematologia (Budep) 30(4):303-311; Ideguchi et al. (2007) Lupus
16(1):59-64; Manner et al. (2008) Am J Med. Sci. 335(5):394-7;
Miesbach et al. (2006) Autoimmune Rev. 6(2):94-7; Gomez-Puerta et
al. (2006) Autoimmune Rev. 6(2):85-8; Gomez-Puerta et al. (2006)
Semin. Arthritis Rheum. 35(5):322-32; Kasamon et al. (2005)
Haematologia 90(3):50-53; Atherson et al. (1998) Medicine 77(3):
195-207; and Canpolat et al. (2008) Clin Pediatr 47(6):593-7. Thus,
a human at risk for developing CAPS can be, e.g., one who has
primary CAPS and/or a cancer that is known to be associated with
CAPS.
[0206] From the above it will be clear that subjects "at risk for
developing a complement-associated disorder" (e.g., an
AP-associated disorder or a CP-associated disorder) are not all the
subjects within a species of interest.
[0207] A subject "suspected of having a complement-associated
disorder" (e.g., an alternative complement pathway-associated
disorder) is one having one or more (e.g., two, three, four, five,
six, seven, eight, nine, or 10 or more) symptoms of the disease.
Symptoms of these disorders will vary depending on the particular
disorder, but are known to those of skill in the art of medicine.
For example, symptoms of DDD include, e.g.: one or both of
hematuria and proteinuria; acute nephritic syndrome; drusen
development and/or visual impairment; acquired partial
lipodystrophy and complications thereof; and the presence of serum
C3 nephritic factor (C3NeF), an autoantibody directed against
C3bBb, the C3 convertase of the alternative complement pathway.
(See, e.g., Appel et al. (2005), supra). Symptoms of aHUS include,
e.g., severe hypertension, proteinuria, uremia, lethargy/fatigue,
irritability, thrombocytopenia, microangiopathic hemolytic anemia,
and renal function impairment (e.g., acute renal failure). Symptoms
of TTP include, e.g., microthrombi, thrombocytopenia, fever, low
ADAMTS13 metalloproteinase expression or activity, fluctuating
central nervous system abnormalities, renal failure,
microangiopathic hemolytic anemia, bruising, purpura, nausea and
vomiting (e.g., resulting from ischemia in the GI tract or from
central nervous system involvement), chest pain due to cardiac
ischemia, seizures, and muscle and joint pain. Symptoms of RA can
include, e.g., stiffness, swelling, fatigue, anemia, weight loss,
fever, and often, crippling pain. Some common symptoms of
rheumatoid arthritis include joint stiffness upon awakening that
lasts an hour or longer; swelling in a specific finger or wrist
joints; swelling in the soft tissue around the joints; and swelling
on both sides of the joint. Swelling can occur with or without
pain, and can worsen progressively or remain the same for years
before progressing. Symptoms of HELLP are known in the art of
medicine and include, e.g., malaise, epigastric pain, nausea,
vomiting, headache, right upper quadrant pain, hypertension,
proteinuria, blurred vision, gastrointestinal bleeding,
hypoglycemia, paresthesia, elevated liver enzymes/liver damage,
anemia (hemolytic anemia), and low platelet count, any of which in
combination with pregnancy or recent pregnancy. (See, e.g., Tomsen
(1995) Am J Obstet Gynecol 172:1876-1890; Sibai (1986) Am J Obstet
Gynecol 162:311-316; and Padden (1999), supra.)
[0208] Symptoms of CAPS are well known in the art of medicine and
include, e.g., histopathological evidence of multiple small vessel
occlusions; the presence of antiphospholipid antibodies (usually at
high titer), vascular thromboses, severe multi-organ dysfunction,
malignant hypertension, acute respiratory distress syndrome,
disseminated intravascular coagulation, microangiopathic hemolytic
anemia, schistocytes, and thrombocytopenia. CAPS can be
distinguished from APS in that patients with CAPS generally present
with severe multiple organ dysfunction or failure, which is
characterized by rapid, diffuse small vessel ischemia and
thromboses predominantly affecting the parenchymal organs. In
contrast, APS is associated with single venous or arterial
medium-to-large blood vessel occlusions. Symptoms of MG include,
e.g., fatigability and a range of muscle weakness-related
conditions including: ptosis (of one or both eyes), diplopia,
unstable gait, depressed or distorted facial expressions, and
difficulty chewing, talking, or swallowing. In some instances, a
subject can present with partial or complete paralysis of the
respiratory muscles. Symptoms of CAD include, e.g., pain, fever,
pallor, anemia, reduced blood flow to the extremities (e.g., with
gangrene), and renal disease or acute renal failure. In some
embodiments, the symptoms can occur following exposure to cold
temperatures.
[0209] From the above it will be clear that subjects "suspected of
having a complement-associated disorder" are not all the subjects
within a species of interest.
[0210] In some embodiments, the methods can include identifying the
subject as one having, suspected of having, or at risk for
developing, a complement-associated disorder in a subject. Suitable
methods for identifying the subject are known in the art. For
example, suitable methods (e.g., sequencing techniques or use of
microarrays) for determining whether a human subject has a
DDD-associated mutation in a CFH, CFHR5, or C3 gene are described
in, e.g., Licht et al. (2006) Kidney Int. 70:42-50; Zipfel et al.
(2006), supra; Ault et al. (1997) J Biol. Chem. 272:25168-75;
Abrera-Abeleda et al. (2006) J Med Genet 43:582-589; Poznansky et
al. (1989) J Immunol. 143:1254-1258; Jansen et al. (1998) Kidney
Int. 53:331-349; and Hegasy et al. (2002) Am J Pathol
161:2027-2034. Methods for detecting the presence of characteristic
DDD-associated electron-dense deposits are also well known in the
art. For example, a medical practitioner can obtain a tissue biopsy
from the kidney of a patient and subject the tissue to electron
microscopy. The medical practitioner may also examine the tissue by
immunofluorescence to detect the presence of C3 using an anti-C3
antibody and/or light microscopy to determine if there is
membranoproliferative glomerulonephritis. See. e.g., Walker et al.
(2007) Mod. Pathol. 20:605-616 and Habib et al. (1975) Kidney Int.
7:204-215. In some embodiments, the identification of a subject as
one having DDD can include assaying a blood sample for the presence
of C3NeF. Methods for detecting the presence of C3NeF in blood are
described in, e.g., Schwertz et al. (2001) Pediatr Allergy Immunol.
12:166-172.
[0211] In some embodiments, the medical practitioner can determine
whether there is increased complement activation in a subject's
serum. Indicia of increased complement activation include, e.g., a
reduction in CH50, a decrease in C3, and an increase in C3dg/C3d.
See, e.g., Appel et al. (2005), supra. In some embodiments, a
medical practitioner can examine a subject's eye for evidence of
the development of drusen and/or other visual pathologies such as
AMD. For example, a medical practitioner can use tests of retinal
function such as, but not limited to, dark adaptation,
electroretinography, and electrooculography (see, e.g., Colville et
al. (2003) Am J Kidney Dis. 42:E2-5).
[0212] Methods for identifying a subject as one having, suspected
of having, or at risk for developing, TTP are also known in the
art. For example, Miyata et al. describe a variety of assays for
measuring ADAMTS13 activity in a biological sample obtained from a
subject (Curr Opin Hematol (2007) 14(3):277-283). Suitable ADAMTS13
activity assays, as well as phenotypically normal ranges of
ADAMTS13 activity in a human subject, are described in, e.g., Tsai
(2003) J. Am. Soc. Nephrol 14:1072-1081; Furlan et al. (1998) New
Eng J Med. 339:1578-1584; Matsumoto et al. (2004) Blood
103:1305-1310; and Mori et al. (2002) Transfusion 42:572-580.
Methods for detecting the presence of inhibitors of ADAMTS13 (e.g.,
autoantibodies that bind to ADAMTS13) in a biological sample
obtained from a subject are known in the art. For example, a serum
sample from a patient can be mixed with a serum sample from a
subject without TTP to detect the presence of anti-ADAMTS13
antibodies. In another example, immunoglobulin protein can be
isolated from patient serum and used in in vitro ADAMTS13 activity
assays to determine if an anti-ADAMTS13 antibody is present. See,
e.g., Dong et al. (2008) Am J Hematol. 83(10):815-817. In some
embodiments, risk of developing ITP can be determined by assessing
whether a patient carries one or more mutations in the ADAMTS13
gene. Suitable methods (e.g., nucleic acid arrays or DNA
sequencing) for detecting a mutation in the ADAMTS13 gene are known
in the art and described in, e.g., Levy et al., supra; Kokame et
al., supra; Licht et al., supra; and Noris et al., supra.
[0213] In addition, methods for identifying a subject as one
having, suspected of having, or at risk for developing aHUS are
known in the art. For example, laboratory tests can be performed to
determine whether a human subject has thrombocytopenia,
microangiopathic hemolytic anemia, or acute renal insufficiency.
Thrombocytopenia can be diagnosed by a medical professional as one
or more of: (i) a platelet count that is less than 150,000/mm.sup.3
(e.g., less than 60,000/mm.sup.3); (ii) a reduction in platelet
survival time, reflecting enhanced platelet disruption in the
circulation; and (iii) giant platelets observed in a peripheral
smear, which is consistent with secondary activation of
thrombocytopoiesis. Microangiopathic hemolytic anemia can be
diagnosed by a medical professional as one or more of: (i)
hemoglobin concentrations that are less than 10 mg/dL (e.g., less
than 6.5 mg/dL); (ii) increased serum lactate dehydrogenase (LDH)
concentrations (>460 U/L); (iii) hyperbilirubinemia,
reticulocytosis, circulating free hemoglobin, and low or
undetectable haptoglobin concentrations; and (iv) the detection of
fragmented red blood cells (schistocytes) with the typical aspect
of burr or helmet cells in the peripheral smear together with a
negative Coombs test. (See, e.g., Kaplan et al. (1992) "Hemolytic
Uremic Syndrome and Thrombotic Thrombocytopenic Purpura." Informa
Health Care (ISBN 0824786637) and Zipfel (2005) "Complement and
Kidney Disease," Springer (ISBN 3764371668).)
[0214] A subject can also be identified as having aHUS by
evaluating blood concentrations of C3 and C4 as a measure of
complement activation or dysregulation. In addition, as is clear
from the foregoing disclosure, a subject can be identified as
having genetic aHUS by identifying the subject as harboring one or
more mutations in a gene associated with aHUS such as CFI, CFB,
CFH, or MCP (supra). Suitable methods for detecting a mutation in a
gene include, e.g., DNA sequencing and nucleic acid array
techniques. (See, e.g., Breslin et al. (2006) Clin Am Soc Nephrol
1:88-99 and Goicoechea de Jorge et al. (2007) Proc Natl Acad Sci
USA 104:240-245.)
[0215] Symptoms characteristic of TMA include, e.g., fever,
microangiopathic hemolytic anemia (schistocytes in a blood smear),
renal failure, thrombocytopenia, and neurological
manifestations.
[0216] Methods for diagnosing a subject as one having, suspected of
having, or at risk for developing, RA are also known in the art of
medicine. For example, a medical practitioner can examine the small
joints of the hands, wrists, feet, and knees to identify
inflammation in a symmetrical distribution. The practitioner may
also perform a number of tests to exclude other types of joint
inflammation including arthritis due to infection or gout. In
addition, rheumatoid arthritis is associated with abnormal
antibodies in the blood circulation of afflicted patients. For
example, an antibody referred to as "rheumatoid factor" is found in
approximately 80% of patients. In another example, anti-citrulline
antibody is present in many patients with rheumatoid arthritis and
thus it is useful in the diagnosis of rheumatoid arthritis when
evaluating patients with unexplained joint inflammation. See, e.g.,
van Venrooij et al. (2008) Ann NY Acad Sci 1143:268-285 and Habib
et al. (2007) Immunol Invest 37(8):849-857. Another antibody called
"the antinuclear antibody" (ANA) is also frequently found in
patients with rheumatoid arthritis. See, e.g., Benucci et al.
(2008) Clin Rheumatol 27(1):91-95; Julkunen et al. (2005) Scan J
Rheumatol 34(2): 122-124; and Miyawaki et al. (2005) J Rheumatol
32(8):1488-1494.
[0217] A medical practitioner can also examine red blood cell
sedimentation rate to help in diagnosing RA in a subject. The
sedimentation rate can be used as a crude measure of the
inflammation of the joints and is usually faster during disease
flares and slower during remissions. Another blood test that can be
used to measure the degree of inflammation present in the body is
the C-reactive protein.
[0218] Furthermore, joint x-rays can also be used to diagnose a
subject as having rheumatoid arthritis. As RA progresses, the
x-rays can show bony erosions typical of rheumatoid arthritis in
the joints. Joint x-rays can also be helpful in monitoring the
progression of disease and joint damage over time. Bone scanning, a
radioactive test procedure, can demonstrate the inflamed
joints.
[0219] Methods for identifying a subject as one having, suspected
of having, or at risk for developing, HELLP are known in the art of
medicine. Hallmark symptoms of HELLP syndrome include hemolysis,
elevated liver enzymes, and low platelet count. Thus, a variety of
tests can be performed on blood from a subject to determine the
level of hemolysis, the concentration of any of a variety of liver
enzymes, and the platelet level in the blood. For example, the
presence of schistocytes and/or elevated free hemoglobin,
bilirubin, or serum LDH levels is an indication of intravascular
hemolysis. Routine laboratory testing can be used to determine the
platelet count as well as the blood level of liver enzymes such as,
but not limited to, aspartate aminotransferase (AST) and alanine
transaminase (ALT). Suitable methods for identifying a subject as
having HELLP syndrome are also described in, e.g., Sibai et al.
(1993), supra; Martin et al. (1990), supra; Padden (1999), supra;
and Gleicher and Buttino (1998) "Principles & Practice of
Medical Therapy in Pregnancy," 3.sup.rd Edition, Appleton &
Lange (ISBN 083857677X).
[0220] Suitable methods for identifying the subject as having MG
can be qualitative or quantitative. For example, a medical
practitioner can examine the status of a subject's motor functions
using a physical examination. Other qualitative tests include,
e.g., an ice-pack test, wherein an ice pack is applied to a
subject's eye (in a case of ocular MG) to determine if one or more
symptoms (e.g., ptosis) are improved by cold (see, e.g., Sethi et
al. (1987) Neurology 37(8): 1383-1385). Other tests include, e.g.,
the "sleep test," which is based on the tendency for MG symptoms to
improve following rest. In some embodiments, quantitative or
semi-quantitative tests can be employed by a medical practitioner
to determine if a subject has, is suspected of having, or is at
risk for developing. MG. For example, a medical practitioner can
perform a test to detect the presence or amount of MG-associated
autoantibodies in a serum sample obtained from a subject.
MG-associated autoantibodies include, e.g., antibodies that bind
to, and modulate the activity of, acetylcholine receptor (AChR),
muscle-specific receptor tyrosine kinase (MuSK), and/or striational
protein. (See, e.g., Conti-Fine et al. (2006), supra). Suitable
assays useful for detecting the presence or amount of an
MG-associated antibody in a biological sample are known in the art
and described in, e.g., Hoch et al. (2001) Nat Med 7:365-368;
Vincent et al. (2004) Semin Neurol. 24:125-133; McConville et al.
(2004) Ann. Neurol. 55:580-584; Boneva et al. (2006) J
Neuroimmunol. 177:119-131; and Romi et al. (2005) Arch Neurol.
62:442-446.
[0221] Additional methods for diagnosing MG include, e.g.,
electrodiagnostic tests (e.g., single-fiber electromyography) and
the Tensilon (or edrophonium) test, which involves injecting a
subject with the acetylcholinesterase inhibitor edrophonium and
monitoring the subject for an improvement in one or more symptoms.
See, e.g., Pascuzzi (2003) Semin Neurol 23(1):83-88; Katirji et al.
(2002) Neurol Clin 20:557-586; and "Guidelines in Electrodiagnostic
Medicine. American Association of Electrodiagnostic Medicine,"
Muscle Nerve 15:229-253.
[0222] A subject can be identified as having CAD using an assay to
detect the presence or amount (titer) of agglutinating
autoantibodies that bind to the I antigen on red blood cells. The
antibodies can be monoclonal (e.g., monoclonal IgM or IgA) or
polyclonal. Suitable methods for detecting these antibodies are
described in, e.g., Christenson and Dacie (1957) Br J Haematol
3:153-164 and Christenson et al. (1957) Br J Haematol 3:262-275. A
subject can also be diagnosed as having CAD using one or more of a
complete blood cell count (CBC), urinalysis, biochemical studies,
and a Coombs test to test for hemolysis in blood. For example,
biochemical studies can be used to detect elevated lactase
dehydrogenase levels, elevated unconjugated bilirubin levels, low
haptoglobin levels, and/or the presence of free plasma hemoglobin,
all of which can be indicative of acute hemolysis. Other tests that
can be used to detect CAD include detecting complement levels in
the serum. For example, due to consumption during the acute phase
of hemolysis, measured plasma complement levels (e.g., C2, C3, and
C4) are decreased in CAD.
[0223] Typical (or infectious) HUS, unlike aHUS, is often
identifiable by a prodrome of diarrhea, often bloody in nature,
which results from infection with a shiga-toxin producing
microorganism. A subject can be identified as having typical HUS
when shiga toxins and/or serum antibodies against shiga toxin or
LPS are detected in the stool of an individual. Suitable methods
for testing for anti-shiga toxin antibodies or LPS are known in the
art. For example, methods for detecting antibodies that bind to
shiga toxins Stx1 and Stx2 or LPS in humans are described in, e.g.,
Ludwig et al. (2001) J Clin Microbiol 39(6):2272-2279.
[0224] Symptoms of this condition are known to those of skill in
the art of medicine and include, e.g., pain, fever, pallor,
icterus, urticarial dermal eruption, hemoglobinuria,
hemoglobinemia, anemia, and renal disease or acute renal failure.
In some embodiments, the symptoms can occur following exposure to
cold temperatures.
[0225] In some embodiments, the methods can include identifying the
subject as one having, suspected of having, or at risk for
developing, PCH. Suitable methods for identifying the subject are
known in the art. For example, a subject can be diagnosed as having
PCH using a Donath-Landsteiner test, which is an assay to detect
the presence of the Donath-Landsteiner antibody in a subject's
serum. The procedure involves incubating three samples--(1) the
subject's serum; (2) normal serum; and (3) a mix of the subject's
serum and normal serum--with P-antigen expressing red blood cells
at 0 to 4.degree. C. Next, the sample is warmed to 37.degree. C.,
and visually inspected for hemolysis. If the Donath-Landsteiner
antibody is present, hemolysis should occur in samples (1) and (3),
but not in (2). See, e.g., Funato et al. (2007) Eur J Haematol
79(5):462; Win et al. (2005) Transfus Med. 15(3):254; Sokol et al.
(1998) Immunohematology 143): 109-12; Eder (2005) Immunohematology
21(2):56-62; and Dacie et al. (1957) Br J Haematol 3:77-87. A
subject can also be diagnosed as having PCH using one or more of a
complete blood cell count (CBC), urinalysis, biochemical studies,
and a Coombs test. For example, biochemical studies can be used to
detect elevated lactase dehydrogenase levels, elevated unconjugated
bilirubin levels, low haptoglobin levels, and/or the presence of
free plasma hemoglobin, all of which can be indicative of acute
hemolysis. Other tests that can be used to detect PCH include
detecting complement levels in the serum. For example, due to
consumption during the acute phase of hemolysis, measured plasma
complement levels (e.g., C2, C3, and C4) are decreased in PCH. See
also, e.g., Nordhagen et al. (1984) Acta Paediatr Scand
73(2):258-262; Lindgren et al. (1985) Transfusion 25(2): 142-4;
Nordhagen et al. (1991) Transfusion 31(2): 190-1; and Garratty
(2001) Transfusion 41(8): 1073-4.
[0226] In some embodiments, the composition can be administered to
a subject prophylactically to prevent, or prevent relapse or
recurrence of, PCH. For example, a subject who previously had an
advanced Mycoplasma infection or who is newly diagnosed with a
PCH-associated neoplasm can be administered a composition described
herein to prevent, lessen the severity of, or prevent a recurrence
of PCH.
[0227] In some embodiments, a C5 inhibitor (e.g., an anti-C5
antibody) described herein can be administered to a subject as a
monotherapy. Alternatively, as described above, the antibody can be
administered to a subject as a combination therapy with another
treatment, e.g., another treatment for DDD, TTP, aHUS, RA, HELLP,
MG, CAD, CAPS, tHUS, Degos disease, or any other
complement-associated disorder described herein. For example, the
combination therapy can include administering to the subject (e.g.,
a human patient) one or more additional agents (e.g.,
anti-coagulants, anti-hypertensives, or corticosteroids) that
provide a therapeutic benefit to the subject who has, or is at risk
of developing, DDD. In some embodiments, the combination therapy
can include administering to the subject (e.g., a human patient) a
C5 inhibitor (e.g., an anti-C5 antibody or an anti-C5a antibody)
and an immunosuppressive agent such as Remicade.RTM. for use in
treating RA. In some embodiments, the C5 inhibitor and the one or
more additional active agents are administered at the same time. In
other embodiments, a C5 inhibitor is administered first in time and
the one or more additional active agents are administered second in
time. In some embodiments, the one or more additional active agents
are administered first in time and the C5 inhibitor is administered
second in time.
[0228] A C5 inhibitor (e.g., an anti-C5 antibody) described herein
can replace or augment a previously or currently administered
therapy. For example, upon treating with an anti-C5 antibody,
administration of the one or more additional active agents can
cease or diminish, e.g., be administered at lower levels. In some
embodiments, administration of the previous therapy can be
maintained. In some embodiments, a previous therapy will be
maintained until the level of the C5 inhibitor (e.g., anti-C5
antibody or an anti-C5a antibody) reaches a level sufficient to
provide a therapeutic effect. The two therapies can be administered
in combination.
[0229] In some embodiments, a C5 inhibitor can be administered to a
patient chronically. For example, a patient chronically treated
with a complement-inhibiting agent (e.g., a C5 inhibitor or a C5a
inhibitor) can be treated for a period of greater than or equal to
2 weeks (e.g., 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,
18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34,
35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51,
or 52 weeks; 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months; or 1,
1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9,
9.5, 10, 10.5, or 12 years or for the remainder of the patient's
life) with the agent in an amount and with a dosing frequency that
are sufficient to maintain a concentration of the agent in the
patient's blood that inhibits or substantially inhibits systemic
complement activity in the patient. To maintain systemic complement
inhibition in a patient, a C5 inhibitor can be chronically
administered to the patient, e.g., once a week, once every two
weeks, twice a week, once a day, once a month, or once every three
weeks. In some embodiments of any of the methods described herein,
the C5 inhibitor can be administered to a patient in an amount and
with a frequency of administration effective to maintain a
concentration of at least: 0.7 (e.g., at least 0.8, 0.9, one, two,
three, four, five, six, seven, eight, nine, or 10 or more) bivalent
C5 inhibitor (e.g., a whole antibody) molecule(s) per every C5
molecule in the patient's blood; or 1.5 (e.g., at least 1.6, 1.7,
1.8, 1.9, two, three, four, five, six, seven, eight, nine, or 10 or
more) monovalent C5 inhibitor (e.g., a single chain anti-C5
antibody or a Fab fragment of the antibody) molecule(s) per every
C5 molecule in the patient's blood. For example, in some
embodiments a monovalent anti-C5 antibody (e.g., a single chain
antibody or a Fab antibody fragment) can be administered to a
patient in an amount and with a frequency effective to maintain a
concentration of at least 1.5 (e.g., at least 1.6, 1.7, 1.8, 1.9,
2, 3, 4, 5, 6, or 7 or more) monovalent anti-C5 antibodies per C5
molecule in the blood. In some embodiments of any of the methods
described herein, an anti-C5 antibody is administered to the
patient in an amount and with a frequency that are effective to
maintain a concentration of at least 40 (e.g., 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, 75, 80, 85, 90, 95, 100, 110, or
120 or more) .mu.g of the antibody per milliliter of the patient's
blood. Exemplary chronic dosing strategies are described herein
(see, e.g., Tables 1 and 2).
[0230] In some embodiments, the C5 inhibitor (or C5a inhibitor) can
be administered to a subject even after one or more symptoms have
been ameliorated. Monitoring a subject (e.g., a human patient) for
an improvement in a complement-associated disorder, as defined
herein, means evaluating the subject for a change in a disease
parameter, e.g., an improvement in one or more symptoms of the
disease. Such symptoms include any of the symptoms of
complement-associated disorders described herein. In some
embodiments, the evaluation is performed at least 1 hour, e.g., at
least 2, 4, 6, 8, 12, 24, or 48 hours, or at least 1 day, 2 days, 4
days, 10 days, 13 days, 20 days or more, or at least 1 week, 2
weeks, 4 weeks, 10 weeks, 13 weeks, 20 weeks or more, after an
administration. The subject can be evaluated in one or more of the
following periods: prior to beginning of treatment; during the
treatment; or after one or more elements of the treatment have been
administered. Evaluating can include evaluating the need for
further treatment, e.g., evaluating whether a dosage, frequency of
administration, or duration of treatment should be altered. It can
also include evaluating the need to add or drop a selected
therapeutic modality, e.g., adding or dropping any of the
treatments for any of the complement-associated disorders described
herein.
[0231] In some embodiments, the complement inhibitor can be
chronically administered to a patient in need thereof in an amount
and with a frequency that are effective to reduce and maintain
serum hemolytic activity at less than or equal to 20 (e.g., 19, 18,
17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, or even below 5) %.
See, e.g., Hill et al. (2005) Blood 106(7):2559. In some
embodiments, the complement inhibitor can be administered to a
patient in an amount and with a frequency that are effective to
maintain serum lactate dehydrogenase (LDH) levels at within at
least 20 (e.g., 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6,
or even below 5) % of the normal range for LDH. See Hill et al.
(2005) supra. In some embodiments, the complement inhibitor is
administered to the patient in an amount and with a frequency that
are effective to maintain a serum LDH level less than 550 (e.g.,
less than 540, 530, 520, 510, 500, 490, 480, 470, 450, 440, 430,
420, 410, 400, or less than 300) IU/L. In some embodiments,
administration (e.g., chronic administration) of a C5 inhibitor
(e.g., an anti-C5 antibody such as eculizumab) or a C5a inhibitor
(e.g., an anti-C5a antibody) results in amelioration of one or more
of a patient's symptoms to within 40 (e.g., 39, 38, 37, 36, 35, 34,
33, 32, 31, 30, 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17,
16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, or even 1) % of
its normal level or value. For example, in some embodiments, the
elevated blood pressure in an aHUS patient treated (e.g.,
chronically treated) with an anti-C5 antibody can be reduced to a
level that is within 40% of the level that is normal for a person
of the patient's age, race, height, weight, sex, and physical
health.
[0232] In some embodiments, the complement inhibitor (e.g., a C5
inhibitor or C5a inhibitor) is administered to a subject even after
the patient has entered clinical remission. Determining clinical
remission of a complement-associated disorder is well within the
skill set of the skilled artisan in medicine. For example, elements
determinative of clinical remission for aHUS are described in,
e.g., Nurnberger et al. (2009) N Engl J Med 360(5):542-544.
Clinical remission for CAPS is described in, e.g., Manner et al.
(2008) Am J Med Sci 335(5):394-397.
[0233] The disclosure also provides methods for allogeneic organ or
tissue transplantation. The method includes transplanting an organ
or tissue into a patient in need thereof, wherein prior to and
following the transplanting a C5 inhibitor is administered to the
patient in an amount and with a frequency effective to
substantially inhibit systemic complement activity in the patient.
As described herein, the C5 inhibitor (e.g., the anti-C5 antibody)
can be administered in an amount and with a frequency to maintain a
concentration of at least one C5 inhibitor molecule (e.g., at least
one anti-C5 antibody) per C5 molecule in the patient's blood. In
some embodiments, a monovalent anti-C5 antibody (e.g., a single
chain antibody or a Fab antibody fragment) can be administered to a
patient in an amount with a frequency effective to maintain a
concentration of at least 1.5 (e.g., at least 1.6, 1.7, 1.8, 1.9,
2, 3, 4, 5, 6, or 7 or more) monovalent anti-C5 antibodies per C5
molecule in the blood. In some embodiments, the C5 inhibitor (e.g.,
the anti-C5 antibody) can be administered to the patient in an
amount and with a frequency to maintain a concentration of at least
at least 40 (e.g., 41, 42, 43, 44, 45, 46, 47, 48, 48, 50, 51, 52,
53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69,
70, 75, 80, 85, 90, 95, 100, 110, or 120 or more) .mu.g of the
inhibitor (e.g., the anti-C5 antibody) in the patient's blood. In
some embodiments, at least 800 (e.g., at least 810, 820, 830, 840,
850, 860, 870, 880, 890, 900, 910, 920, 930, 940, 950, 960, 970,
980, 990, 1000, 1100, or 1200 or more) mg of the anti-C5 antibody
(e.g., eculizumab) is administered to the patient less than 24
(e.g., less than 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12,
11, 10, 9, 8, 7, 6, 5, 4, 3, or less than 2) hours prior to
transplanting the organ or tissue to the patient. In some
embodiments, the methods can also include, prior to the
transplanting, contacting (e.g., soaking) the donor organ or tissue
with a C5 inhibitor (e.g., an anti-C5 antibody such as eculizumab)
for an amount of time and under conditions that inhibit complement
activation in the organ or tissue upon transplantation. The organ
can be, e.g., skin, a kidney, heart, lung, limb (e.g., finger or
toe), or liver. In some embodiments, the methods can include
administering a C5 inhibitor (e.g., an anti-C5 antibody) to the
donor patient prior to removal of the organ or tissue for
transplant. The patient can have, be at risk for developing, or be
suspected of having aHUS. In some embodiments, at least 700 (e.g.,
at least 710, 720, 730, 740, 750, 760, 770, 780, 790, 800, 810,
820, 830, 840, 850, 860, 870, 880, 890, 900, 910, 920, 930, 940,
950, 960, 970, 980, 990, 1000, 1100, or 1200 or more) mg of the
anti-C5 antibody is administered to the patient less than 24 (e.g.,
less than 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10,
9, 8, 7, 6, 5, 4, 3, or less than 2) hours following the
transplanting. In some embodiments, the anti-C5 antibody is
chronically administered to the patient following the
transplanting. For example, the anti-C5 antibody can be chronically
administered to the patient for at least 9 weeks (e.g., 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,
29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45,
46, 47, 48, 49, 50, 51, or 52 weeks: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
11, or 12 months; or 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6,
6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 10.5, or 12 years or for the
remainder of the patient's life) under the following dosing
schedule: at least 700 (e.g., at least 710, 720, 730, 740, 750,
760, 770, 780, 790, 800, 810, 820, 830, 840, 850, 860, 870, 880,
890, 900, 910, 920, 930, 940, 950, 960, 970, 980, 990, 1000, 1100,
or 1200 or more) mg of the anti-C5 antibody less than 24 hours
after transplanting the organ or tissue; at least 700 (e.g., at
least 710, 720, 730, 740, 750, 760, 770, 780, 790, 800, 810, 820,
830, 840, 850, 860, 870, 880, 890, 900, 910, 920, 930, 940, 950,
960, 970, 980, 990, 1000, 1100, or 1200 or more) mg of the anti-C5
antibody once per week for four weeks after the initial
post-transplant dose; at least 700 (e.g., at least 710, 720, 730,
740, 750, 760, 770, 780, 790, 800, 810, 820, 830, 840, 850, 860,
870, 880, 890, 900, 910, 920, 930, 940, 950, 960, 970, 980, 990,
1000, 1100, or 1200 or more) mg of the anti-C5 antibody once during
the fifth week; and at least 700 (e.g., at least 710, 720, 730,
740, 750, 760, 770, 780, 790, 800, 810, 820, 830, 840, 850, 860,
870, 880, 890, 900, 910, 920, 930, 940, 950, 960, 970, 980, 990,
1000, 1100, or 1200 or more) mg of the anti-C5 antibody bi-weekly
thereafter for the remainder of the dosing schedule. In a preferred
embodiment, the anti-C5 antibody is administered such that the
first four doses are at least 900 mg of the antibody; 1200 mg is
administered on the fifth week; and 1200 mg is administered to the
patient bi-weekly thereafter for the remainder of the chronic
treatment schedule. Addition exemplary dosing schedules are
provided in Tables 1 and 2.
[0234] In some embodiments, the methods include administering an
immunosuppressant to the patient. Suitable immunosuppressants for
use in the methods include, but are not limited to, ATG or ALG,
OKT3, daclizumab, basiliximab, corticosteroids, 15-deoxyspergualin,
cyclosporins, tacrolimus, azathioprine, methotrexate, mycophenolate
mofetil, 6-mercaptopurine, bredinin, brequinar, leflunamide,
cyclophosphamide, sirolimus, anti-CD4 monoclonal antibodies,
CTLA4-Ig, anti-CD154 monoclonal antibodies, anti-LFA1 monoclonal
antibodies, anti-LFA-3 monoclonal antibodies, anti-CD2 monoclonal
antibodies, and anti-CD45 antibodies.
[0235] Types of organs or tissues that can be transplanted using
the methods described herein include, e.g., heart, kidney, lung,
pancreas, liver, vascular tissue, eye, cornea, lens, skin, bone
marrow, muscle, connective tissue, gastrointestinal tissue, nervous
tissue, bone, stem cells, islets, cartilage, hepatocytes, and
hematopoietic cells.
[0236] In some embodiments, the transplant methods will result in
prolongation of the graft in the recipient patient by at least one
month (e.g., three, four, five, six, seven, eight, nine, 10, 11, or
12 months or 1, 2, 3, 4, 5, 6, 7, 8, 9, or even 10 years or
more).
[0237] Ex Vivo Approaches.
[0238] An ex vivo strategy for treating or preventing a
complement-associated disorder (e.g., an AP-associated disorder or
a CP-associated disorder) can involve transfecting or transducing
one or more cells obtained from a subject with a polynucleotide
encoding a complement inhibitor (e.g., an anti-C5 antibody,
anti-C5a antibody, or a nucleic acid (e.g., a siRNA) that binds to
and promotes inactivation of a C5 mRNA in a mammalian cell)
described herein. For example, the cells can be transfected with a
single vector encoding a heavy and light chain of an antibody that
binds to C5 protein, or the cells can be transfected with a first
vector encoding a heavy chain and a second vector encoding a light
chain of the antibody.
[0239] The transfected or transduced cells are then returned to the
subject. The cells can be any of a wide range of types including,
without limitation, hemopoietic cells (e.g., bone marrow cells,
macrophages, monocytes, dendritic cells, T cells, or B cells),
fibroblasts, epithelial cells, endothelial cells, keratinocytes, or
muscle cells. Such cells can act as a source (e.g., sustained or
periodic source) of the C5 inhibitor (e.g., anti-C5 antibody,
anti-C5a antibody, or nucleic acid (above)) for as long as they
survive in the subject. In some embodiments, the vectors and/or
cells can be configured for inducible or repressible expression of
the C5 inhibitor (see, e.g., Schockett et al. (1996) Proc Natl Acad
Sci USA 93: 5173-5176 and U.S. Pat. No. 7,056,897).
[0240] Preferably, the cells are obtained from the subject
(autologous), but can potentially be obtained from a subject of the
same species other than the subject (allogeneic).
[0241] Suitable methods for obtaining cells from a subject and
transducing or transfecting the cells are known in the art of
molecular biology. For example, the transduction step can be
accomplished by any standard means used for ex vivo gene therapy,
including calcium phosphate, lipofection, electroporation, viral
infection (see above), and biolistic gene transfer. (See, e.g.,
Sambrook et al. (supra) and Ausubel et al. (1992) "Current
Protocols in Molecular Biology." Greene Publishing Associates.)
Alternatively, liposomes or polymeric microparticles can be used.
Cells that have been successfully transduced can be selected, for
example, for expression of the coding sequence or of a drug
resistance gene.
Kits
[0242] The disclosure also features articles of manufacture or
kits, which include a container with a label; and a composition
containing one or more complement inhibitors described herein. For
example, the kit can contain one or more of an anti-C5a antibody,
an anti-C5 antibody, and a nucleic acid (e.g., an siRNA or
antisense nucleic acid) that binds to and promotes inactivation of
a C5 mRNA in a mammalian cell. The label indicates that the
composition is to be administered to a subject (e.g., a human)
having, suspected of having, or at risk for developing, a
complement-associated disorder (e.g., an AP- or CP-associated
disorder) such as DDD, aHUS, TTP, HELLP, RA, AMD, tHUS, MG, CAD,
PCH, CAPS, Degos disease, or any other complement
pathway-associated disorder described herein. The kit can,
optionally, include a means for administering the composition to
the subject. For example, the kits can include one or more
syringes.
[0243] In some embodiments, the kits can further include one or
more additional active agents such as any of those described
herein. For example, the kits can include one or more
corticosteroids, anti-hypertensives, immunosuppressives, and
anti-seizure agents.
[0244] The following examples are intended to illustrate, not
limit, the invention.
Example 1
[0245] A human adult patient is identified by a medical
practitioner as having an inherited form of aHUS. Once a week for
four weeks the patient is administered a composition containing
eculizumab at a dose of 900 mg. The patient then receives at least
1200 mg of eculizumab once during the fifth week and at least 1200
mg of eculizumab bi-weekly thereafter. The patient and medical
practitioner observe a substantial improvement in at least two
known symptoms of aHUS during the initial treatment. Eculizumab is
chronically administered to the patient even after the medical
practitioner determines that the aHUS is in remission.
Example 2
[0246] A human patient weighing around 25 kg is identified by a
medical practitioner as having aHUS. Once a week for two weeks the
patient is administered a composition containing eculizumab at a
dose of at least 600 mg. The patient then receives at least 600 mg
of eculizumab once during the third week and at least 600 mg of
eculizumab bi-weekly thereafter. The patient and medical
practitioner observe a substantial improvement in at least two
known symptoms of aHUS during the initial treatment. Eculizumab is
chronically administered to the patient even after the medical
practitioner determines that the aHUS is in remission in order to
prevent a recurrence of aHUS in the patient.
Example 3
[0247] A human patient weighing around 35 kg is identified by a
medical practitioner as having CAPS. Once a week for two weeks the
patient is administered a composition containing eculizumab at a
dose of at least 600 mg. The patient then receives at least 900 mg
of eculizumab once during the third week and at least 900 mg of
eculizumab bi-weekly thereafter. The patient and medical
practitioner observe a substantial improvement in at least two
known symptoms of CAPS during the initial treatment. Eculizumab is
chronically administered to the patient even after the medical
practitioner determines that the CAPS is in remission in order to
prevent, or substantially reduce the likelihood of, a recurrence of
CAPS in the patient.
Example 4
[0248] A human patient weighing around 7 kg is identified by a
medical practitioner as having aHUS. The patient has TMA in her
kidneys as a result of the aHUS. For one week the patient is
administered a composition containing eculizumab at a dose of at
least 300 mg. The patient then receives at least 300 mg of
eculizumab once during the second week and at least 300 mg of
eculizumab every three weeks thereafter. The patient and medical
practitioner observe a substantial improvement in at least two
known symptoms of aHUS during the initial treatment. The medical
practitioner also observes that the TMA in the patient's kidneys
resolves and no new TMA occurs while the patient is being
chronically administered eculizumab. Eculizumab is chronically
administered to the patient even after the medical practitioner
determines that the aHUS is in remission in order to prevent, or
substantially reduce the likelihood of, a recurrence of aHUS in the
patient and any further damage to her kidneys that could result
from recurrence.
Example 5
[0249] A human patient in need of a kidney transplant is
intravenously administered eculizumab at a dose of 1200 mg less
than 24 hours before the transplant operation. An allogeneic kidney
is transplanted into the patient. Less than 24 hours after the
kidney transplant, the patient is administered another 1200 mg of
eculizumab. Once a week for four weeks following the first
post-operation dose of eculizumab, the patient receives 900 mg of
eculizumab. The patient receives 1200 mg of eculizumab on the fifth
week after the initial post-operation dose of eculizumab and then
is maintained on a dosing schedule that includes 1200 mg of
eculizumab bi-weekly thereafter. The medical practitioner observes
a substantial improvement in the survival of the transplanted
kidney in the patient.
Example 6
[0250] A human patient is identified by a medical practitioner as
having anti-AChR antibody positive MG. Once a week for four weeks
the patient is administered a composition containing eculizumab at
a dose of 600 mg. Eculizumab is administered as a 35-minute
intravenous infusion. The patient and medical practitioner observe
a substantial improvement in at least two known symptoms of MG
during the initial treatment. One week after the initial four week
treatment, the patient receives intravenously administered
"maintenance doses" of eculizumab every two weeks, each dose being
900 mg, until the medical practitioner determines that the MG is in
remission.
Example 7
[0251] A human patient presenting with D-penicillamine-induced MG
is intravenously administered every two weeks a composition
containing eculizumab at a dose of 900 mg. The patient and medical
practitioner observe a substantial reduction in overall severity of
the patient's MG symptoms during initial treatment. The patient is
maintained on the same treatment regimen until the medical
practitioner determines that the MG is in remission.
[0252] While the present disclosure has been described with
reference to the specific embodiments thereof, it should be
understood by those skilled in the art that various changes may be
made and equivalents may be substituted without departing from the
true spirit and scope of the disclosure. In addition, many
modifications may be made to adapt a particular situation,
material, composition of matter, process, process step or steps, to
the objective, spirit and scope of the present disclosure. All such
modifications are intended to be within the scope of the
disclosure.
Sequence CWU 1
1
2611676PRTHomo sapiens 1Met Gly Leu Leu Gly Ile Leu Cys Phe Leu Ile
Phe Leu Gly Lys Thr 1 5 10 15 Trp Gly Gln Glu Gln Thr Tyr Val Ile
Ser Ala Pro Lys Ile Phe Arg 20 25 30 Val Gly Ala Ser Glu Asn Ile
Val Ile Gln Val Tyr Gly Tyr Thr Glu 35 40 45 Ala Phe Asp Ala Thr
Ile Ser Ile Lys Ser Tyr Pro Asp Lys Lys Phe 50 55 60 Ser Tyr Ser
Ser Gly His Val His Leu Ser Ser Glu Asn Lys Phe Gln 65 70 75 80 Asn
Ser Ala Ile Leu Thr Ile Gln Pro Lys Gln Leu Pro Gly Gly Gln 85 90
95 Asn Pro Val Ser Tyr Val Tyr Leu Glu Val Val Ser Lys His Phe Ser
100 105 110 Lys Ser Lys Arg Met Pro Ile Thr Tyr Asp Asn Gly Phe Leu
Phe Ile 115 120 125 His Thr Asp Lys Pro Val Tyr Thr Pro Asp Gln Ser
Val Lys Val Arg 130 135 140 Val Tyr Ser Leu Asn Asp Asp Leu Lys Pro
Ala Lys Arg Glu Thr Val 145 150 155 160 Leu Thr Phe Ile Asp Pro Glu
Gly Ser Glu Val Asp Met Val Glu Glu 165 170 175 Ile Asp His Ile Gly
Ile Ile Ser Phe Pro Asp Phe Lys Ile Pro Ser 180 185 190 Asn Pro Arg
Tyr Gly Met Trp Thr Ile Lys Ala Lys Tyr Lys Glu Asp 195 200 205 Phe
Ser Thr Thr Gly Thr Ala Tyr Phe Glu Val Lys Glu Tyr Val Leu 210 215
220 Pro His Phe Ser Val Ser Ile Glu Pro Glu Tyr Asn Phe Ile Gly Tyr
225 230 235 240 Lys Asn Phe Lys Asn Phe Glu Ile Thr Ile Lys Ala Arg
Tyr Phe Tyr 245 250 255 Asn Lys Val Val Thr Glu Ala Asp Val Tyr Ile
Thr Phe Gly Ile Arg 260 265 270 Glu Asp Leu Lys Asp Asp Gln Lys Glu
Met Met Gln Thr Ala Met Gln 275 280 285 Asn Thr Met Leu Ile Asn Gly
Ile Ala Gln Val Thr Phe Asp Ser Glu 290 295 300 Thr Ala Val Lys Glu
Leu Ser Tyr Tyr Ser Leu Glu Asp Leu Asn Asn 305 310 315 320 Lys Tyr
Leu Tyr Ile Ala Val Thr Val Ile Glu Ser Thr Gly Gly Phe 325 330 335
Ser Glu Glu Ala Glu Ile Pro Gly Ile Lys Tyr Val Leu Ser Pro Tyr 340
345 350 Lys Leu Asn Leu Val Ala Thr Pro Leu Phe Leu Lys Pro Gly Ile
Pro 355 360 365 Tyr Pro Ile Lys Val Gln Val Lys Asp Ser Leu Asp Gln
Leu Val Gly 370 375 380 Gly Val Pro Val Ile Leu Asn Ala Gln Thr Ile
Asp Val Asn Gln Glu 385 390 395 400 Thr Ser Asp Leu Asp Pro Ser Lys
Ser Val Thr Arg Val Asp Asp Gly 405 410 415 Val Ala Ser Phe Val Leu
Asn Leu Pro Ser Gly Val Thr Val Leu Glu 420 425 430 Phe Asn Val Lys
Thr Asp Ala Pro Asp Leu Pro Glu Glu Asn Gln Ala 435 440 445 Arg Glu
Gly Tyr Arg Ala Ile Ala Tyr Ser Ser Leu Ser Gln Ser Tyr 450 455 460
Leu Tyr Ile Asp Trp Thr Asp Asn His Lys Ala Leu Leu Val Gly Glu 465
470 475 480 His Leu Asn Ile Ile Val Thr Pro Lys Ser Pro Tyr Ile Asp
Lys Ile 485 490 495 Thr His Tyr Asn Tyr Leu Ile Leu Ser Lys Gly Lys
Ile Ile His Phe 500 505 510 Gly Thr Arg Glu Lys Phe Ser Asp Ala Ser
Tyr Gln Ser Ile Asn Ile 515 520 525 Pro Val Thr Gln Asn Met Val Pro
Ser Ser Arg Leu Leu Val Tyr Tyr 530 535 540 Ile Val Thr Gly Glu Gln
Thr Ala Glu Leu Val Ser Asp Ser Val Trp 545 550 555 560 Leu Asn Ile
Glu Glu Lys Cys Gly Asn Gln Leu Gln Val His Leu Ser 565 570 575 Pro
Asp Ala Asp Ala Tyr Ser Pro Gly Gln Thr Val Ser Leu Asn Met 580 585
590 Ala Thr Gly Met Asp Ser Trp Val Ala Leu Ala Ala Val Asp Ser Ala
595 600 605 Val Tyr Gly Val Gln Arg Gly Ala Lys Lys Pro Leu Glu Arg
Val Phe 610 615 620 Gln Phe Leu Glu Lys Ser Asp Leu Gly Cys Gly Ala
Gly Gly Gly Leu 625 630 635 640 Asn Asn Ala Asn Val Phe His Leu Ala
Gly Leu Thr Phe Leu Thr Asn 645 650 655 Ala Asn Ala Asp Asp Ser Gln
Glu Asn Asp Glu Pro Cys Lys Glu Ile 660 665 670 Leu Arg Pro Arg Arg
Thr Leu Gln Lys Lys Ile Glu Glu Ile Ala Ala 675 680 685 Lys Tyr Lys
His Ser Val Val Lys Lys Cys Cys Tyr Asp Gly Ala Cys 690 695 700 Val
Asn Asn Asp Glu Thr Cys Glu Gln Arg Ala Ala Arg Ile Ser Leu 705 710
715 720 Gly Pro Arg Cys Ile Lys Ala Phe Thr Glu Cys Cys Val Val Ala
Ser 725 730 735 Gln Leu Arg Ala Asn Ile Ser His Lys Asp Met Gln Leu
Gly Arg Leu 740 745 750 His Met Lys Thr Leu Leu Pro Val Ser Lys Pro
Glu Ile Arg Ser Tyr 755 760 765 Phe Pro Glu Ser Trp Leu Trp Glu Val
His Leu Val Pro Arg Arg Lys 770 775 780 Gln Leu Gln Phe Ala Leu Pro
Asp Ser Leu Thr Thr Trp Glu Ile Gln 785 790 795 800 Gly Ile Gly Ile
Ser Asn Thr Gly Ile Cys Val Ala Asp Thr Val Lys 805 810 815 Ala Lys
Val Phe Lys Asp Val Phe Leu Glu Met Asn Ile Pro Tyr Ser 820 825 830
Val Val Arg Gly Glu Gln Ile Gln Leu Lys Gly Thr Val Tyr Asn Tyr 835
840 845 Arg Thr Ser Gly Met Gln Phe Cys Val Lys Met Ser Ala Val Glu
Gly 850 855 860 Ile Cys Thr Ser Glu Ser Pro Val Ile Asp His Gln Gly
Thr Lys Ser 865 870 875 880 Ser Lys Cys Val Arg Gln Lys Val Glu Gly
Ser Ser Ser His Leu Val 885 890 895 Thr Phe Thr Val Leu Pro Leu Glu
Ile Gly Leu His Asn Ile Asn Phe 900 905 910 Ser Leu Glu Thr Trp Phe
Gly Lys Glu Ile Leu Val Lys Thr Leu Arg 915 920 925 Val Val Pro Glu
Gly Val Lys Arg Glu Ser Tyr Ser Gly Val Thr Leu 930 935 940 Asp Pro
Arg Gly Ile Tyr Gly Thr Ile Ser Arg Arg Lys Glu Phe Pro 945 950 955
960 Tyr Arg Ile Pro Leu Asp Leu Val Pro Lys Thr Glu Ile Lys Arg Ile
965 970 975 Leu Ser Val Lys Gly Leu Leu Val Gly Glu Ile Leu Ser Ala
Val Leu 980 985 990 Ser Gln Glu Gly Ile Asn Ile Leu Thr His Leu Pro
Lys Gly Ser Ala 995 1000 1005 Glu Ala Glu Leu Met Ser Val Val Pro
Val Phe Tyr Val Phe His 1010 1015 1020 Tyr Leu Glu Thr Gly Asn His
Trp Asn Ile Phe His Ser Asp Pro 1025 1030 1035 Leu Ile Glu Lys Gln
Lys Leu Lys Lys Lys Leu Lys Glu Gly Met 1040 1045 1050 Leu Ser Ile
Met Ser Tyr Arg Asn Ala Asp Tyr Ser Tyr Ser Val 1055 1060 1065 Trp
Lys Gly Gly Ser Ala Ser Thr Trp Leu Thr Ala Phe Ala Leu 1070 1075
1080 Arg Val Leu Gly Gln Val Asn Lys Tyr Val Glu Gln Asn Gln Asn
1085 1090 1095 Ser Ile Cys Asn Ser Leu Leu Trp Leu Val Glu Asn Tyr
Gln Leu 1100 1105 1110 Asp Asn Gly Ser Phe Lys Glu Asn Ser Gln Tyr
Gln Pro Ile Lys 1115 1120 1125 Leu Gln Gly Thr Leu Pro Val Glu Ala
Arg Glu Asn Ser Leu Tyr 1130 1135 1140 Leu Thr Ala Phe Thr Val Ile
Gly Ile Arg Lys Ala Phe Asp Ile 1145 1150 1155 Cys Pro Leu Val Lys
Ile Asp Thr Ala Leu Ile Lys Ala Asp Asn 1160 1165 1170 Phe Leu Leu
Glu Asn Thr Leu Pro Ala Gln Ser Thr Phe Thr Leu 1175 1180 1185 Ala
Ile Ser Ala Tyr Ala Leu Ser Leu Gly Asp Lys Thr His Pro 1190 1195
1200 Gln Phe Arg Ser Ile Val Ser Ala Leu Lys Arg Glu Ala Leu Val
1205 1210 1215 Lys Gly Asn Pro Pro Ile Tyr Arg Phe Trp Lys Asp Asn
Leu Gln 1220 1225 1230 His Lys Asp Ser Ser Val Pro Asn Thr Gly Thr
Ala Arg Met Val 1235 1240 1245 Glu Thr Thr Ala Tyr Ala Leu Leu Thr
Ser Leu Asn Leu Lys Asp 1250 1255 1260 Ile Asn Tyr Val Asn Pro Val
Ile Lys Trp Leu Ser Glu Glu Gln 1265 1270 1275 Arg Tyr Gly Gly Gly
Phe Tyr Ser Thr Gln Asp Thr Ile Asn Ala 1280 1285 1290 Ile Glu Gly
Leu Thr Glu Tyr Ser Leu Leu Val Lys Gln Leu Arg 1295 1300 1305 Leu
Ser Met Asp Ile Asp Val Ser Tyr Lys His Lys Gly Ala Leu 1310 1315
1320 His Asn Tyr Lys Met Thr Asp Lys Asn Phe Leu Gly Arg Pro Val
1325 1330 1335 Glu Val Leu Leu Asn Asp Asp Leu Ile Val Ser Thr Gly
Phe Gly 1340 1345 1350 Ser Gly Leu Ala Thr Val His Val Thr Thr Val
Val His Lys Thr 1355 1360 1365 Ser Thr Ser Glu Glu Val Cys Ser Phe
Tyr Leu Lys Ile Asp Thr 1370 1375 1380 Gln Asp Ile Glu Ala Ser His
Tyr Arg Gly Tyr Gly Asn Ser Asp 1385 1390 1395 Tyr Lys Arg Ile Val
Ala Cys Ala Ser Tyr Lys Pro Ser Arg Glu 1400 1405 1410 Glu Ser Ser
Ser Gly Ser Ser His Ala Val Met Asp Ile Ser Leu 1415 1420 1425 Pro
Thr Gly Ile Ser Ala Asn Glu Glu Asp Leu Lys Ala Leu Val 1430 1435
1440 Glu Gly Val Asp Gln Leu Phe Thr Asp Tyr Gln Ile Lys Asp Gly
1445 1450 1455 His Val Ile Leu Gln Leu Asn Ser Ile Pro Ser Ser Asp
Phe Leu 1460 1465 1470 Cys Val Arg Phe Arg Ile Phe Glu Leu Phe Glu
Val Gly Phe Leu 1475 1480 1485 Ser Pro Ala Thr Phe Thr Val Tyr Glu
Tyr His Arg Pro Asp Lys 1490 1495 1500 Gln Cys Thr Met Phe Tyr Ser
Thr Ser Asn Ile Lys Ile Gln Lys 1505 1510 1515 Val Cys Glu Gly Ala
Ala Cys Lys Cys Val Glu Ala Asp Cys Gly 1520 1525 1530 Gln Met Gln
Glu Glu Leu Asp Leu Thr Ile Ser Ala Glu Thr Arg 1535 1540 1545 Lys
Gln Thr Ala Cys Lys Pro Glu Ile Ala Tyr Ala Tyr Lys Val 1550 1555
1560 Ser Ile Thr Ser Ile Thr Val Glu Asn Val Phe Val Lys Tyr Lys
1565 1570 1575 Ala Thr Leu Leu Asp Ile Tyr Lys Thr Gly Glu Ala Val
Ala Glu 1580 1585 1590 Lys Asp Ser Glu Ile Thr Phe Ile Lys Lys Val
Thr Cys Thr Asn 1595 1600 1605 Ala Glu Leu Val Lys Gly Arg Gln Tyr
Leu Ile Met Gly Lys Glu 1610 1615 1620 Ala Leu Gln Ile Lys Tyr Asn
Phe Ser Phe Arg Tyr Ile Tyr Pro 1625 1630 1635 Leu Asp Ser Leu Thr
Trp Ile Glu Tyr Trp Pro Arg Asp Thr Thr 1640 1645 1650 Cys Ser Ser
Cys Gln Ala Phe Leu Ala Asn Leu Asp Glu Phe Ala 1655 1660 1665 Glu
Asp Ile Phe Leu Asn Gly Cys 1670 1675 21658PRTHomo sapiens 2Gln Glu
Gln Thr Tyr Val Ile Ser Ala Pro Lys Ile Phe Arg Val Gly 1 5 10 15
Ala Ser Glu Asn Ile Val Ile Gln Val Tyr Gly Tyr Thr Glu Ala Phe 20
25 30 Asp Ala Thr Ile Ser Ile Lys Ser Tyr Pro Asp Lys Lys Phe Ser
Tyr 35 40 45 Ser Ser Gly His Val His Leu Ser Ser Glu Asn Lys Phe
Gln Asn Ser 50 55 60 Ala Ile Leu Thr Ile Gln Pro Lys Gln Leu Pro
Gly Gly Gln Asn Pro 65 70 75 80 Val Ser Tyr Val Tyr Leu Glu Val Val
Ser Lys His Phe Ser Lys Ser 85 90 95 Lys Arg Met Pro Ile Thr Tyr
Asp Asn Gly Phe Leu Phe Ile His Thr 100 105 110 Asp Lys Pro Val Tyr
Thr Pro Asp Gln Ser Val Lys Val Arg Val Tyr 115 120 125 Ser Leu Asn
Asp Asp Leu Lys Pro Ala Lys Arg Glu Thr Val Leu Thr 130 135 140 Phe
Ile Asp Pro Glu Gly Ser Glu Val Asp Met Val Glu Glu Ile Asp 145 150
155 160 His Ile Gly Ile Ile Ser Phe Pro Asp Phe Lys Ile Pro Ser Asn
Pro 165 170 175 Arg Tyr Gly Met Trp Thr Ile Lys Ala Lys Tyr Lys Glu
Asp Phe Ser 180 185 190 Thr Thr Gly Thr Ala Tyr Phe Glu Val Lys Glu
Tyr Val Leu Pro His 195 200 205 Phe Ser Val Ser Ile Glu Pro Glu Tyr
Asn Phe Ile Gly Tyr Lys Asn 210 215 220 Phe Lys Asn Phe Glu Ile Thr
Ile Lys Ala Arg Tyr Phe Tyr Asn Lys 225 230 235 240 Val Val Thr Glu
Ala Asp Val Tyr Ile Thr Phe Gly Ile Arg Glu Asp 245 250 255 Leu Lys
Asp Asp Gln Lys Glu Met Met Gln Thr Ala Met Gln Asn Thr 260 265 270
Met Leu Ile Asn Gly Ile Ala Gln Val Thr Phe Asp Ser Glu Thr Ala 275
280 285 Val Lys Glu Leu Ser Tyr Tyr Ser Leu Glu Asp Leu Asn Asn Lys
Tyr 290 295 300 Leu Tyr Ile Ala Val Thr Val Ile Glu Ser Thr Gly Gly
Phe Ser Glu 305 310 315 320 Glu Ala Glu Ile Pro Gly Ile Lys Tyr Val
Leu Ser Pro Tyr Lys Leu 325 330 335 Asn Leu Val Ala Thr Pro Leu Phe
Leu Lys Pro Gly Ile Pro Tyr Pro 340 345 350 Ile Lys Val Gln Val Lys
Asp Ser Leu Asp Gln Leu Val Gly Gly Val 355 360 365 Pro Val Ile Leu
Asn Ala Gln Thr Ile Asp Val Asn Gln Glu Thr Ser 370 375 380 Asp Leu
Asp Pro Ser Lys Ser Val Thr Arg Val Asp Asp Gly Val Ala 385 390 395
400 Ser Phe Val Leu Asn Leu Pro Ser Gly Val Thr Val Leu Glu Phe Asn
405 410 415 Val Lys Thr Asp Ala Pro Asp Leu Pro Glu Glu Asn Gln Ala
Arg Glu 420 425 430 Gly Tyr Arg Ala Ile Ala Tyr Ser Ser Leu Ser Gln
Ser Tyr Leu Tyr 435 440 445 Ile Asp Trp Thr Asp Asn His Lys Ala Leu
Leu Val Gly Glu His Leu 450 455 460 Asn Ile Ile Val Thr Pro Lys Ser
Pro Tyr Ile Asp Lys Ile Thr His 465 470 475 480 Tyr Asn Tyr Leu Ile
Leu Ser Lys Gly Lys Ile Ile His Phe Gly Thr 485 490 495 Arg Glu Lys
Phe Ser Asp Ala Ser Tyr Gln Ser Ile Asn Ile Pro Val 500 505 510 Thr
Gln Asn Met Val Pro Ser Ser Arg Leu Leu Val Tyr Tyr Ile Val 515 520
525 Thr Gly Glu Gln Thr Ala Glu Leu Val Ser Asp Ser Val Trp Leu Asn
530 535 540 Ile Glu Glu Lys Cys Gly Asn Gln Leu Gln Val His Leu Ser
Pro Asp 545 550 555 560 Ala Asp Ala Tyr Ser Pro Gly Gln Thr Val Ser
Leu Asn Met Ala Thr 565 570 575 Gly Met Asp Ser Trp Val Ala Leu Ala
Ala Val Asp Ser Ala Val Tyr 580 585 590
Gly Val Gln Arg Gly Ala Lys Lys Pro Leu Glu Arg Val Phe Gln Phe 595
600 605 Leu Glu Lys Ser Asp Leu Gly Cys Gly Ala Gly Gly Gly Leu Asn
Asn 610 615 620 Ala Asn Val Phe His Leu Ala Gly Leu Thr Phe Leu Thr
Asn Ala Asn 625 630 635 640 Ala Asp Asp Ser Gln Glu Asn Asp Glu Pro
Cys Lys Glu Ile Leu Arg 645 650 655 Pro Arg Arg Thr Leu Gln Lys Lys
Ile Glu Glu Ile Ala Ala Lys Tyr 660 665 670 Lys His Ser Val Val Lys
Lys Cys Cys Tyr Asp Gly Ala Cys Val Asn 675 680 685 Asn Asp Glu Thr
Cys Glu Gln Arg Ala Ala Arg Ile Ser Leu Gly Pro 690 695 700 Arg Cys
Ile Lys Ala Phe Thr Glu Cys Cys Val Val Ala Ser Gln Leu 705 710 715
720 Arg Ala Asn Ile Ser His Lys Asp Met Gln Leu Gly Arg Leu His Met
725 730 735 Lys Thr Leu Leu Pro Val Ser Lys Pro Glu Ile Arg Ser Tyr
Phe Pro 740 745 750 Glu Ser Trp Leu Trp Glu Val His Leu Val Pro Arg
Arg Lys Gln Leu 755 760 765 Gln Phe Ala Leu Pro Asp Ser Leu Thr Thr
Trp Glu Ile Gln Gly Ile 770 775 780 Gly Ile Ser Asn Thr Gly Ile Cys
Val Ala Asp Thr Val Lys Ala Lys 785 790 795 800 Val Phe Lys Asp Val
Phe Leu Glu Met Asn Ile Pro Tyr Ser Val Val 805 810 815 Arg Gly Glu
Gln Ile Gln Leu Lys Gly Thr Val Tyr Asn Tyr Arg Thr 820 825 830 Ser
Gly Met Gln Phe Cys Val Lys Met Ser Ala Val Glu Gly Ile Cys 835 840
845 Thr Ser Glu Ser Pro Val Ile Asp His Gln Gly Thr Lys Ser Ser Lys
850 855 860 Cys Val Arg Gln Lys Val Glu Gly Ser Ser Ser His Leu Val
Thr Phe 865 870 875 880 Thr Val Leu Pro Leu Glu Ile Gly Leu His Asn
Ile Asn Phe Ser Leu 885 890 895 Glu Thr Trp Phe Gly Lys Glu Ile Leu
Val Lys Thr Leu Arg Val Val 900 905 910 Pro Glu Gly Val Lys Arg Glu
Ser Tyr Ser Gly Val Thr Leu Asp Pro 915 920 925 Arg Gly Ile Tyr Gly
Thr Ile Ser Arg Arg Lys Glu Phe Pro Tyr Arg 930 935 940 Ile Pro Leu
Asp Leu Val Pro Lys Thr Glu Ile Lys Arg Ile Leu Ser 945 950 955 960
Val Lys Gly Leu Leu Val Gly Glu Ile Leu Ser Ala Val Leu Ser Gln 965
970 975 Glu Gly Ile Asn Ile Leu Thr His Leu Pro Lys Gly Ser Ala Glu
Ala 980 985 990 Glu Leu Met Ser Val Val Pro Val Phe Tyr Val Phe His
Tyr Leu Glu 995 1000 1005 Thr Gly Asn His Trp Asn Ile Phe His Ser
Asp Pro Leu Ile Glu 1010 1015 1020 Lys Gln Lys Leu Lys Lys Lys Leu
Lys Glu Gly Met Leu Ser Ile 1025 1030 1035 Met Ser Tyr Arg Asn Ala
Asp Tyr Ser Tyr Ser Val Trp Lys Gly 1040 1045 1050 Gly Ser Ala Ser
Thr Trp Leu Thr Ala Phe Ala Leu Arg Val Leu 1055 1060 1065 Gly Gln
Val Asn Lys Tyr Val Glu Gln Asn Gln Asn Ser Ile Cys 1070 1075 1080
Asn Ser Leu Leu Trp Leu Val Glu Asn Tyr Gln Leu Asp Asn Gly 1085
1090 1095 Ser Phe Lys Glu Asn Ser Gln Tyr Gln Pro Ile Lys Leu Gln
Gly 1100 1105 1110 Thr Leu Pro Val Glu Ala Arg Glu Asn Ser Leu Tyr
Leu Thr Ala 1115 1120 1125 Phe Thr Val Ile Gly Ile Arg Lys Ala Phe
Asp Ile Cys Pro Leu 1130 1135 1140 Val Lys Ile Asp Thr Ala Leu Ile
Lys Ala Asp Asn Phe Leu Leu 1145 1150 1155 Glu Asn Thr Leu Pro Ala
Gln Ser Thr Phe Thr Leu Ala Ile Ser 1160 1165 1170 Ala Tyr Ala Leu
Ser Leu Gly Asp Lys Thr His Pro Gln Phe Arg 1175 1180 1185 Ser Ile
Val Ser Ala Leu Lys Arg Glu Ala Leu Val Lys Gly Asn 1190 1195 1200
Pro Pro Ile Tyr Arg Phe Trp Lys Asp Asn Leu Gln His Lys Asp 1205
1210 1215 Ser Ser Val Pro Asn Thr Gly Thr Ala Arg Met Val Glu Thr
Thr 1220 1225 1230 Ala Tyr Ala Leu Leu Thr Ser Leu Asn Leu Lys Asp
Ile Asn Tyr 1235 1240 1245 Val Asn Pro Val Ile Lys Trp Leu Ser Glu
Glu Gln Arg Tyr Gly 1250 1255 1260 Gly Gly Phe Tyr Ser Thr Gln Asp
Thr Ile Asn Ala Ile Glu Gly 1265 1270 1275 Leu Thr Glu Tyr Ser Leu
Leu Val Lys Gln Leu Arg Leu Ser Met 1280 1285 1290 Asp Ile Asp Val
Ser Tyr Lys His Lys Gly Ala Leu His Asn Tyr 1295 1300 1305 Lys Met
Thr Asp Lys Asn Phe Leu Gly Arg Pro Val Glu Val Leu 1310 1315 1320
Leu Asn Asp Asp Leu Ile Val Ser Thr Gly Phe Gly Ser Gly Leu 1325
1330 1335 Ala Thr Val His Val Thr Thr Val Val His Lys Thr Ser Thr
Ser 1340 1345 1350 Glu Glu Val Cys Ser Phe Tyr Leu Lys Ile Asp Thr
Gln Asp Ile 1355 1360 1365 Glu Ala Ser His Tyr Arg Gly Tyr Gly Asn
Ser Asp Tyr Lys Arg 1370 1375 1380 Ile Val Ala Cys Ala Ser Tyr Lys
Pro Ser Arg Glu Glu Ser Ser 1385 1390 1395 Ser Gly Ser Ser His Ala
Val Met Asp Ile Ser Leu Pro Thr Gly 1400 1405 1410 Ile Ser Ala Asn
Glu Glu Asp Leu Lys Ala Leu Val Glu Gly Val 1415 1420 1425 Asp Gln
Leu Phe Thr Asp Tyr Gln Ile Lys Asp Gly His Val Ile 1430 1435 1440
Leu Gln Leu Asn Ser Ile Pro Ser Ser Asp Phe Leu Cys Val Arg 1445
1450 1455 Phe Arg Ile Phe Glu Leu Phe Glu Val Gly Phe Leu Ser Pro
Ala 1460 1465 1470 Thr Phe Thr Val Tyr Glu Tyr His Arg Pro Asp Lys
Gln Cys Thr 1475 1480 1485 Met Phe Tyr Ser Thr Ser Asn Ile Lys Ile
Gln Lys Val Cys Glu 1490 1495 1500 Gly Ala Ala Cys Lys Cys Val Glu
Ala Asp Cys Gly Gln Met Gln 1505 1510 1515 Glu Glu Leu Asp Leu Thr
Ile Ser Ala Glu Thr Arg Lys Gln Thr 1520 1525 1530 Ala Cys Lys Pro
Glu Ile Ala Tyr Ala Tyr Lys Val Ser Ile Thr 1535 1540 1545 Ser Ile
Thr Val Glu Asn Val Phe Val Lys Tyr Lys Ala Thr Leu 1550 1555 1560
Leu Asp Ile Tyr Lys Thr Gly Glu Ala Val Ala Glu Lys Asp Ser 1565
1570 1575 Glu Ile Thr Phe Ile Lys Lys Val Thr Cys Thr Asn Ala Glu
Leu 1580 1585 1590 Val Lys Gly Arg Gln Tyr Leu Ile Met Gly Lys Glu
Ala Leu Gln 1595 1600 1605 Ile Lys Tyr Asn Phe Ser Phe Arg Tyr Ile
Tyr Pro Leu Asp Ser 1610 1615 1620 Leu Thr Trp Ile Glu Tyr Trp Pro
Arg Asp Thr Thr Cys Ser Ser 1625 1630 1635 Cys Gln Ala Phe Leu Ala
Asn Leu Asp Glu Phe Ala Glu Asp Ile 1640 1645 1650 Phe Leu Asn Gly
Cys 1655 3999PRTHomo sapiens 3Thr Leu Gln Lys Lys Ile Glu Glu Ile
Ala Ala Lys Tyr Lys His Ser 1 5 10 15 Val Val Lys Lys Cys Cys Tyr
Asp Gly Ala Cys Val Asn Asn Asp Glu 20 25 30 Thr Cys Glu Gln Arg
Ala Ala Arg Ile Ser Leu Gly Pro Arg Cys Ile 35 40 45 Lys Ala Phe
Thr Glu Cys Cys Val Val Ala Ser Gln Leu Arg Ala Asn 50 55 60 Ile
Ser His Lys Asp Met Gln Leu Gly Arg Leu His Met Lys Thr Leu 65 70
75 80 Leu Pro Val Ser Lys Pro Glu Ile Arg Ser Tyr Phe Pro Glu Ser
Trp 85 90 95 Leu Trp Glu Val His Leu Val Pro Arg Arg Lys Gln Leu
Gln Phe Ala 100 105 110 Leu Pro Asp Ser Leu Thr Thr Trp Glu Ile Gln
Gly Ile Gly Ile Ser 115 120 125 Asn Thr Gly Ile Cys Val Ala Asp Thr
Val Lys Ala Lys Val Phe Lys 130 135 140 Asp Val Phe Leu Glu Met Asn
Ile Pro Tyr Ser Val Val Arg Gly Glu 145 150 155 160 Gln Ile Gln Leu
Lys Gly Thr Val Tyr Asn Tyr Arg Thr Ser Gly Met 165 170 175 Gln Phe
Cys Val Lys Met Ser Ala Val Glu Gly Ile Cys Thr Ser Glu 180 185 190
Ser Pro Val Ile Asp His Gln Gly Thr Lys Ser Ser Lys Cys Val Arg 195
200 205 Gln Lys Val Glu Gly Ser Ser Ser His Leu Val Thr Phe Thr Val
Leu 210 215 220 Pro Leu Glu Ile Gly Leu His Asn Ile Asn Phe Ser Leu
Glu Thr Trp 225 230 235 240 Phe Gly Lys Glu Ile Leu Val Lys Thr Leu
Arg Val Val Pro Glu Gly 245 250 255 Val Lys Arg Glu Ser Tyr Ser Gly
Val Thr Leu Asp Pro Arg Gly Ile 260 265 270 Tyr Gly Thr Ile Ser Arg
Arg Lys Glu Phe Pro Tyr Arg Ile Pro Leu 275 280 285 Asp Leu Val Pro
Lys Thr Glu Ile Lys Arg Ile Leu Ser Val Lys Gly 290 295 300 Leu Leu
Val Gly Glu Ile Leu Ser Ala Val Leu Ser Gln Glu Gly Ile 305 310 315
320 Asn Ile Leu Thr His Leu Pro Lys Gly Ser Ala Glu Ala Glu Leu Met
325 330 335 Ser Val Val Pro Val Phe Tyr Val Phe His Tyr Leu Glu Thr
Gly Asn 340 345 350 His Trp Asn Ile Phe His Ser Asp Pro Leu Ile Glu
Lys Gln Lys Leu 355 360 365 Lys Lys Lys Leu Lys Glu Gly Met Leu Ser
Ile Met Ser Tyr Arg Asn 370 375 380 Ala Asp Tyr Ser Tyr Ser Val Trp
Lys Gly Gly Ser Ala Ser Thr Trp 385 390 395 400 Leu Thr Ala Phe Ala
Leu Arg Val Leu Gly Gln Val Asn Lys Tyr Val 405 410 415 Glu Gln Asn
Gln Asn Ser Ile Cys Asn Ser Leu Leu Trp Leu Val Glu 420 425 430 Asn
Tyr Gln Leu Asp Asn Gly Ser Phe Lys Glu Asn Ser Gln Tyr Gln 435 440
445 Pro Ile Lys Leu Gln Gly Thr Leu Pro Val Glu Ala Arg Glu Asn Ser
450 455 460 Leu Tyr Leu Thr Ala Phe Thr Val Ile Gly Ile Arg Lys Ala
Phe Asp 465 470 475 480 Ile Cys Pro Leu Val Lys Ile Asp Thr Ala Leu
Ile Lys Ala Asp Asn 485 490 495 Phe Leu Leu Glu Asn Thr Leu Pro Ala
Gln Ser Thr Phe Thr Leu Ala 500 505 510 Ile Ser Ala Tyr Ala Leu Ser
Leu Gly Asp Lys Thr His Pro Gln Phe 515 520 525 Arg Ser Ile Val Ser
Ala Leu Lys Arg Glu Ala Leu Val Lys Gly Asn 530 535 540 Pro Pro Ile
Tyr Arg Phe Trp Lys Asp Asn Leu Gln His Lys Asp Ser 545 550 555 560
Ser Val Pro Asn Thr Gly Thr Ala Arg Met Val Glu Thr Thr Ala Tyr 565
570 575 Ala Leu Leu Thr Ser Leu Asn Leu Lys Asp Ile Asn Tyr Val Asn
Pro 580 585 590 Val Ile Lys Trp Leu Ser Glu Glu Gln Arg Tyr Gly Gly
Gly Phe Tyr 595 600 605 Ser Thr Gln Asp Thr Ile Asn Ala Ile Glu Gly
Leu Thr Glu Tyr Ser 610 615 620 Leu Leu Val Lys Gln Leu Arg Leu Ser
Met Asp Ile Asp Val Ser Tyr 625 630 635 640 Lys His Lys Gly Ala Leu
His Asn Tyr Lys Met Thr Asp Lys Asn Phe 645 650 655 Leu Gly Arg Pro
Val Glu Val Leu Leu Asn Asp Asp Leu Ile Val Ser 660 665 670 Thr Gly
Phe Gly Ser Gly Leu Ala Thr Val His Val Thr Thr Val Val 675 680 685
His Lys Thr Ser Thr Ser Glu Glu Val Cys Ser Phe Tyr Leu Lys Ile 690
695 700 Asp Thr Gln Asp Ile Glu Ala Ser His Tyr Arg Gly Tyr Gly Asn
Ser 705 710 715 720 Asp Tyr Lys Arg Ile Val Ala Cys Ala Ser Tyr Lys
Pro Ser Arg Glu 725 730 735 Glu Ser Ser Ser Gly Ser Ser His Ala Val
Met Asp Ile Ser Leu Pro 740 745 750 Thr Gly Ile Ser Ala Asn Glu Glu
Asp Leu Lys Ala Leu Val Glu Gly 755 760 765 Val Asp Gln Leu Phe Thr
Asp Tyr Gln Ile Lys Asp Gly His Val Ile 770 775 780 Leu Gln Leu Asn
Ser Ile Pro Ser Ser Asp Phe Leu Cys Val Arg Phe 785 790 795 800 Arg
Ile Phe Glu Leu Phe Glu Val Gly Phe Leu Ser Pro Ala Thr Phe 805 810
815 Thr Val Tyr Glu Tyr His Arg Pro Asp Lys Gln Cys Thr Met Phe Tyr
820 825 830 Ser Thr Ser Asn Ile Lys Ile Gln Lys Val Cys Glu Gly Ala
Ala Cys 835 840 845 Lys Cys Val Glu Ala Asp Cys Gly Gln Met Gln Glu
Glu Leu Asp Leu 850 855 860 Thr Ile Ser Ala Glu Thr Arg Lys Gln Thr
Ala Cys Lys Pro Glu Ile 865 870 875 880 Ala Tyr Ala Tyr Lys Val Ser
Ile Thr Ser Ile Thr Val Glu Asn Val 885 890 895 Phe Val Lys Tyr Lys
Ala Thr Leu Leu Asp Ile Tyr Lys Thr Gly Glu 900 905 910 Ala Val Ala
Glu Lys Asp Ser Glu Ile Thr Phe Ile Lys Lys Val Thr 915 920 925 Cys
Thr Asn Ala Glu Leu Val Lys Gly Arg Gln Tyr Leu Ile Met Gly 930 935
940 Lys Glu Ala Leu Gln Ile Lys Tyr Asn Phe Ser Phe Arg Tyr Ile Tyr
945 950 955 960 Pro Leu Asp Ser Leu Thr Trp Ile Glu Tyr Trp Pro Arg
Asp Thr Thr 965 970 975 Cys Ser Ser Cys Gln Ala Phe Leu Ala Asn Leu
Asp Glu Phe Ala Glu 980 985 990 Asp Ile Phe Leu Asn Gly Cys 995
4655PRTHomo sapiens 4Gln Glu Gln Thr Tyr Val Ile Ser Ala Pro Lys
Ile Phe Arg Val Gly 1 5 10 15 Ala Ser Glu Asn Ile Val Ile Gln Val
Tyr Gly Tyr Thr Glu Ala Phe 20 25 30 Asp Ala Thr Ile Ser Ile Lys
Ser Tyr Pro Asp Lys Lys Phe Ser Tyr 35 40 45 Ser Ser Gly His Val
His Leu Ser Ser Glu Asn Lys Phe Gln Asn Ser 50 55 60 Ala Ile Leu
Thr Ile Gln Pro Lys Gln Leu Pro Gly Gly Gln Asn Pro 65 70 75 80 Val
Ser Tyr Val Tyr Leu Glu Val Val Ser Lys His Phe Ser Lys Ser 85 90
95 Lys Arg Met Pro Ile Thr Tyr Asp Asn Gly Phe Leu Phe Ile His Thr
100 105 110 Asp Lys Pro Val Tyr Thr Pro Asp Gln Ser Val Lys Val Arg
Val Tyr 115 120 125 Ser Leu Asn Asp Asp Leu Lys Pro Ala Lys Arg Glu
Thr Val Leu Thr 130 135 140 Phe Ile Asp Pro Glu Gly Ser Glu Val Asp
Met Val Glu Glu Ile Asp 145 150 155 160 His Ile Gly Ile Ile Ser Phe
Pro Asp Phe Lys Ile Pro Ser Asn Pro 165 170 175 Arg Tyr Gly Met Trp
Thr Ile Lys Ala Lys Tyr Lys Glu Asp Phe Ser 180 185 190 Thr Thr Gly
Thr Ala Tyr Phe Glu Val Lys Glu Tyr Val Leu Pro His 195
200 205 Phe Ser Val Ser Ile Glu Pro Glu Tyr Asn Phe Ile Gly Tyr Lys
Asn 210 215 220 Phe Lys Asn Phe Glu Ile Thr Ile Lys Ala Arg Tyr Phe
Tyr Asn Lys 225 230 235 240 Val Val Thr Glu Ala Asp Val Tyr Ile Thr
Phe Gly Ile Arg Glu Asp 245 250 255 Leu Lys Asp Asp Gln Lys Glu Met
Met Gln Thr Ala Met Gln Asn Thr 260 265 270 Met Leu Ile Asn Gly Ile
Ala Gln Val Thr Phe Asp Ser Glu Thr Ala 275 280 285 Val Lys Glu Leu
Ser Tyr Tyr Ser Leu Glu Asp Leu Asn Asn Lys Tyr 290 295 300 Leu Tyr
Ile Ala Val Thr Val Ile Glu Ser Thr Gly Gly Phe Ser Glu 305 310 315
320 Glu Ala Glu Ile Pro Gly Ile Lys Tyr Val Leu Ser Pro Tyr Lys Leu
325 330 335 Asn Leu Val Ala Thr Pro Leu Phe Leu Lys Pro Gly Ile Pro
Tyr Pro 340 345 350 Ile Lys Val Gln Val Lys Asp Ser Leu Asp Gln Leu
Val Gly Gly Val 355 360 365 Pro Val Ile Leu Asn Ala Gln Thr Ile Asp
Val Asn Gln Glu Thr Ser 370 375 380 Asp Leu Asp Pro Ser Lys Ser Val
Thr Arg Val Asp Asp Gly Val Ala 385 390 395 400 Ser Phe Val Leu Asn
Leu Pro Ser Gly Val Thr Val Leu Glu Phe Asn 405 410 415 Val Lys Thr
Asp Ala Pro Asp Leu Pro Glu Glu Asn Gln Ala Arg Glu 420 425 430 Gly
Tyr Arg Ala Ile Ala Tyr Ser Ser Leu Ser Gln Ser Tyr Leu Tyr 435 440
445 Ile Asp Trp Thr Asp Asn His Lys Ala Leu Leu Val Gly Glu His Leu
450 455 460 Asn Ile Ile Val Thr Pro Lys Ser Pro Tyr Ile Asp Lys Ile
Thr His 465 470 475 480 Tyr Asn Tyr Leu Ile Leu Ser Lys Gly Lys Ile
Ile His Phe Gly Thr 485 490 495 Arg Glu Lys Phe Ser Asp Ala Ser Tyr
Gln Ser Ile Asn Ile Pro Val 500 505 510 Thr Gln Asn Met Val Pro Ser
Ser Arg Leu Leu Val Tyr Tyr Ile Val 515 520 525 Thr Gly Glu Gln Thr
Ala Glu Leu Val Ser Asp Ser Val Trp Leu Asn 530 535 540 Ile Glu Glu
Lys Cys Gly Asn Gln Leu Gln Val His Leu Ser Pro Asp 545 550 555 560
Ala Asp Ala Tyr Ser Pro Gly Gln Thr Val Ser Leu Asn Met Ala Thr 565
570 575 Gly Met Asp Ser Trp Val Ala Leu Ala Ala Val Asp Ser Ala Val
Tyr 580 585 590 Gly Val Gln Arg Gly Ala Lys Lys Pro Leu Glu Arg Val
Phe Gln Phe 595 600 605 Leu Glu Lys Ser Asp Leu Gly Cys Gly Ala Gly
Gly Gly Leu Asn Asn 610 615 620 Ala Asn Val Phe His Leu Ala Gly Leu
Thr Phe Leu Thr Asn Ala Asn 625 630 635 640 Ala Asp Asp Ser Gln Glu
Asn Asp Glu Pro Cys Lys Glu Ile Leu 645 650 655 521PRTHomo sapiens
5Val Ile Asp His Gln Gly Thr Lys Ser Ser Lys Cys Val Arg Gln Lys 1
5 10 15 Val Glu Gly Ser Ser 20 65PRTHomo sapiens 6Lys Ser Ser Lys
Cys 1 5 7127PRTHomo sapiens 7Asn Phe Ser Leu Glu Thr Trp Phe Gly
Lys Glu Ile Leu Val Lys Thr 1 5 10 15 Leu Arg Val Val Pro Glu Gly
Val Lys Arg Glu Ser Tyr Ser Gly Val 20 25 30 Thr Leu Asp Pro Arg
Gly Ile Tyr Gly Thr Ile Ser Arg Arg Lys Glu 35 40 45 Phe Pro Tyr
Arg Ile Pro Leu Asp Leu Val Pro Lys Thr Glu Ile Lys 50 55 60 Arg
Ile Leu Ser Val Lys Gly Leu Leu Val Gly Glu Ile Leu Ser Ala 65 70
75 80 Val Leu Ser Gln Glu Gly Ile Asn Ile Leu Thr His Leu Pro Lys
Gly 85 90 95 Ser Ala Glu Ala Glu Leu Met Ser Val Val Pro Val Phe
Tyr Val Phe 100 105 110 His Tyr Leu Glu Thr Gly Asn His Trp Asn Ile
Phe His Ser Asp 115 120 125 8200PRTHomo sapiens 8Ser Glu Ser Pro
Val Ile Asp His Gln Gly Thr Lys Ser Ser Lys Cys 1 5 10 15 Val Arg
Gln Lys Val Glu Gly Ser Ser Ser His Leu Val Thr Phe Thr 20 25 30
Val Leu Pro Leu Glu Ile Gly Leu His Asn Ile Asn Phe Ser Leu Glu 35
40 45 Thr Trp Phe Gly Lys Glu Ile Leu Val Lys Thr Leu Arg Val Val
Pro 50 55 60 Glu Gly Val Lys Arg Glu Ser Tyr Ser Gly Val Thr Leu
Asp Pro Arg 65 70 75 80 Gly Ile Tyr Gly Thr Ile Ser Arg Arg Lys Glu
Phe Pro Tyr Arg Ile 85 90 95 Pro Leu Asp Leu Val Pro Lys Thr Glu
Ile Lys Arg Ile Leu Ser Val 100 105 110 Lys Gly Leu Leu Val Gly Glu
Ile Leu Ser Ala Val Leu Ser Gln Glu 115 120 125 Gly Ile Asn Ile Leu
Thr His Leu Pro Lys Gly Ser Ala Glu Ala Glu 130 135 140 Leu Met Ser
Val Val Pro Val Phe Tyr Val Phe His Tyr Leu Glu Thr 145 150 155 160
Gly Asn His Trp Asn Ile Phe His Ser Asp Pro Leu Ile Glu Lys Gln 165
170 175 Lys Leu Lys Lys Lys Leu Lys Glu Gly Met Leu Ser Ile Met Ser
Tyr 180 185 190 Arg Asn Ala Asp Tyr Ser Tyr Ser 195 200 930PRTHomo
sapiens 9Ser His Lys Asp Met Gln Leu Gly Arg Leu His Met Lys Thr
Leu Leu 1 5 10 15 Pro Val Ser Lys Pro Glu Ile Arg Ser Tyr Phe Pro
Glu Ser 20 25 30 10325PRTHomo sapiens 10Ser His Lys Asp Met Gln Leu
Gly Arg Leu His Met Lys Thr Leu Leu 1 5 10 15 Pro Val Ser Lys Pro
Glu Ile Arg Ser Tyr Phe Pro Glu Ser Trp Leu 20 25 30 Trp Glu Val
His Leu Val Pro Arg Arg Lys Gln Leu Gln Phe Ala Leu 35 40 45 Pro
Asp Ser Leu Thr Thr Trp Glu Ile Gln Gly Ile Gly Ile Ser Asn 50 55
60 Thr Gly Ile Cys Val Ala Asp Thr Val Lys Ala Lys Val Phe Lys Asp
65 70 75 80 Val Phe Leu Glu Met Asn Ile Pro Tyr Ser Val Val Arg Gly
Glu Gln 85 90 95 Ile Gln Leu Lys Gly Thr Val Tyr Asn Tyr Arg Thr
Ser Gly Met Gln 100 105 110 Phe Cys Val Lys Met Ser Ala Val Glu Gly
Ile Cys Thr Ser Glu Ser 115 120 125 Pro Val Ile Asp His Gln Gly Thr
Lys Ser Ser Lys Cys Val Arg Gln 130 135 140 Lys Val Glu Gly Ser Ser
Ser His Leu Val Thr Phe Thr Val Leu Pro 145 150 155 160 Leu Glu Ile
Gly Leu His Asn Ile Asn Phe Ser Leu Glu Thr Trp Phe 165 170 175 Gly
Lys Glu Ile Leu Val Lys Thr Leu Arg Val Val Pro Glu Gly Val 180 185
190 Lys Arg Glu Ser Tyr Ser Gly Val Thr Leu Asp Pro Arg Gly Ile Tyr
195 200 205 Gly Thr Ile Ser Arg Arg Lys Glu Phe Pro Tyr Arg Ile Pro
Leu Asp 210 215 220 Leu Val Pro Lys Thr Glu Ile Lys Arg Ile Leu Ser
Val Lys Gly Leu 225 230 235 240 Leu Val Gly Glu Ile Leu Ser Ala Val
Leu Ser Gln Glu Gly Ile Asn 245 250 255 Ile Leu Thr His Leu Pro Lys
Gly Ser Ala Glu Ala Glu Leu Met Ser 260 265 270 Val Val Pro Val Phe
Tyr Val Phe His Tyr Leu Glu Thr Gly Asn His 275 280 285 Trp Asn Ile
Phe His Ser Asp Pro Leu Ile Glu Lys Gln Lys Leu Lys 290 295 300 Lys
Lys Leu Lys Glu Gly Met Leu Ser Ile Met Ser Tyr Arg Asn Ala 305 310
315 320 Asp Tyr Ser Tyr Ser 325 1117PRTHomo sapiens 11Asp His Gln
Gly Thr Lys Ser Ser Lys Cys Val Arg Gln Lys Val Glu 1 5 10 15 Gly
1274PRTHomo sapiens 12Thr Leu Gln Lys Lys Ile Glu Glu Ile Ala Ala
Lys Tyr Lys His Ser 1 5 10 15 Val Val Lys Lys Cys Cys Tyr Asp Gly
Ala Cys Val Asn Asn Asp Glu 20 25 30 Thr Cys Glu Gln Arg Ala Ala
Arg Ile Ser Leu Gly Pro Arg Cys Ile 35 40 45 Lys Ala Phe Thr Glu
Cys Cys Val Val Ala Ser Gln Leu Arg Ala Asn 50 55 60 Ile Ser His
Lys Asp Met Gln Leu Gly Arg 65 70 1320PRTHomo sapiens 13Cys Cys Tyr
Asp Gly Ala Cys Val Asn Asn Asp Glu Thr Cys Glu Gln 1 5 10 15 Arg
Ala Ala Arg 20 1418PRTHomo sapiens 14Lys Cys Cys Tyr Asp Gly Ala
Cys Val Asn Asn Asp Glu Thr Cys Glu 1 5 10 15 Gln Arg 1510PRTHomo
sapiens 15Val Asn Asn Asp Glu Thr Cys Glu Gln Arg 1 5 10 166PRTHomo
sapiens 16Val Asn Asn Asp Glu Thr 1 5 179PRTHomo sapiens 17Ala Ala
Arg Ile Ser Leu Gly Pro Arg 1 5 1819PRTHomo sapiens 18Cys Cys Tyr
Asp Gly Ala Cys Val Asn Asn Asp Glu Thr Cys Glu Gln 1 5 10 15 Arg
Ala Ala 1918PRTHomo sapiens 19Cys Cys Tyr Asp Gly Ala Cys Val Asn
Asn Asp Glu Thr Cys Glu Gln 1 5 10 15 Arg Ala 2017PRTHomo sapiens
20Cys Cys Tyr Asp Gly Ala Cys Val Asn Asn Asp Glu Thr Cys Glu Gln 1
5 10 15 Arg 2116PRTHomo sapiens 21Cys Cys Tyr Asp Gly Ala Cys Val
Asn Asn Asp Glu Thr Cys Glu Gln 1 5 10 15 2215PRTHomo sapiens 22Cys
Cys Tyr Asp Gly Ala Cys Val Asn Asn Asp Glu Thr Cys Glu 1 5 10 15
2319PRTHomo sapiens 23Cys Tyr Asp Gly Ala Cys Val Asn Asn Asp Glu
Thr Cys Glu Gln Arg 1 5 10 15 Ala Ala Arg 2418PRTHomo sapiens 24Tyr
Asp Gly Ala Cys Val Asn Asn Asp Glu Thr Cys Glu Gln Arg Ala 1 5 10
15 Ala Arg 2519PRTHomo sapiens 25Cys Tyr Asp Gly Ala Cys Val Asn
Asn Asp Glu Thr Cys Glu Gln Arg 1 5 10 15 Ala Ala Arg 26925PRTHomo
sapiens 26Leu His Met Lys Thr Leu Leu Pro Val Ser Lys Pro Glu Ile
Arg Ser 1 5 10 15 Tyr Phe Pro Glu Ser Trp Leu Trp Glu Val His Leu
Val Pro Arg Arg 20 25 30 Lys Gln Leu Gln Phe Ala Leu Pro Asp Ser
Leu Thr Thr Trp Glu Ile 35 40 45 Gln Gly Ile Gly Ile Ser Asn Thr
Gly Ile Cys Val Ala Asp Thr Val 50 55 60 Lys Ala Lys Val Phe Lys
Asp Val Phe Leu Glu Met Asn Ile Pro Tyr 65 70 75 80 Ser Val Val Arg
Gly Glu Gln Ile Gln Leu Lys Gly Thr Val Tyr Asn 85 90 95 Tyr Arg
Thr Ser Gly Met Gln Phe Cys Val Lys Met Ser Ala Val Glu 100 105 110
Gly Ile Cys Thr Ser Glu Ser Pro Val Ile Asp His Gln Gly Thr Lys 115
120 125 Ser Ser Lys Cys Val Arg Gln Lys Val Glu Gly Ser Ser Ser His
Leu 130 135 140 Val Thr Phe Thr Val Leu Pro Leu Glu Ile Gly Leu His
Asn Ile Asn 145 150 155 160 Phe Ser Leu Glu Thr Trp Phe Gly Lys Glu
Ile Leu Val Lys Thr Leu 165 170 175 Arg Val Val Pro Glu Gly Val Lys
Arg Glu Ser Tyr Ser Gly Val Thr 180 185 190 Leu Asp Pro Arg Gly Ile
Tyr Gly Thr Ile Ser Arg Arg Lys Glu Phe 195 200 205 Pro Tyr Arg Ile
Pro Leu Asp Leu Val Pro Lys Thr Glu Ile Lys Arg 210 215 220 Ile Leu
Ser Val Lys Gly Leu Leu Val Gly Glu Ile Leu Ser Ala Val 225 230 235
240 Leu Ser Gln Glu Gly Ile Asn Ile Leu Thr His Leu Pro Lys Gly Ser
245 250 255 Ala Glu Ala Glu Leu Met Ser Val Val Pro Val Phe Tyr Val
Phe His 260 265 270 Tyr Leu Glu Thr Gly Asn His Trp Asn Ile Phe His
Ser Asp Pro Leu 275 280 285 Ile Glu Lys Gln Lys Leu Lys Lys Lys Leu
Lys Glu Gly Met Leu Ser 290 295 300 Ile Met Ser Tyr Arg Asn Ala Asp
Tyr Ser Tyr Ser Val Trp Lys Gly 305 310 315 320 Gly Ser Ala Ser Thr
Trp Leu Thr Ala Phe Ala Leu Arg Val Leu Gly 325 330 335 Gln Val Asn
Lys Tyr Val Glu Gln Asn Gln Asn Ser Ile Cys Asn Ser 340 345 350 Leu
Leu Trp Leu Val Glu Asn Tyr Gln Leu Asp Asn Gly Ser Phe Lys 355 360
365 Glu Asn Ser Gln Tyr Gln Pro Ile Lys Leu Gln Gly Thr Leu Pro Val
370 375 380 Glu Ala Arg Glu Asn Ser Leu Tyr Leu Thr Ala Phe Thr Val
Ile Gly 385 390 395 400 Ile Arg Lys Ala Phe Asp Ile Cys Pro Leu Val
Lys Ile Asp Thr Ala 405 410 415 Leu Ile Lys Ala Asp Asn Phe Leu Leu
Glu Asn Thr Leu Pro Ala Gln 420 425 430 Ser Thr Phe Thr Leu Ala Ile
Ser Ala Tyr Ala Leu Ser Leu Gly Asp 435 440 445 Lys Thr His Pro Gln
Phe Arg Ser Ile Val Ser Ala Leu Lys Arg Glu 450 455 460 Ala Leu Val
Lys Gly Asn Pro Pro Ile Tyr Arg Phe Trp Lys Asp Asn 465 470 475 480
Leu Gln His Lys Asp Ser Ser Val Pro Asn Thr Gly Thr Ala Arg Met 485
490 495 Val Glu Thr Thr Ala Tyr Ala Leu Leu Thr Ser Leu Asn Leu Lys
Asp 500 505 510 Ile Asn Tyr Val Asn Pro Val Ile Lys Trp Leu Ser Glu
Glu Gln Arg 515 520 525 Tyr Gly Gly Gly Phe Tyr Ser Thr Gln Asp Thr
Ile Asn Ala Ile Glu 530 535 540 Gly Leu Thr Glu Tyr Ser Leu Leu Val
Lys Gln Leu Arg Leu Ser Met 545 550 555 560 Asp Ile Asp Val Ser Tyr
Lys His Lys Gly Ala Leu His Asn Tyr Lys 565 570 575 Met Thr Asp Lys
Asn Phe Leu Gly Arg Pro Val Glu Val Leu Leu Asn 580 585 590 Asp Asp
Leu Ile Val Ser Thr Gly Phe Gly Ser Gly Leu Ala Thr Val 595 600 605
His Val Thr Thr Val Val His Lys Thr Ser Thr Ser Glu Glu Val Cys 610
615 620 Ser Phe Tyr Leu Lys Ile Asp Thr Gln Asp Ile Glu Ala Ser His
Tyr 625 630 635 640 Arg Gly Tyr Gly Asn Ser Asp Tyr Lys Arg Ile Val
Ala Cys Ala Ser 645 650 655 Tyr Lys Pro Ser Arg Glu Glu Ser Ser Ser
Gly Ser Ser His Ala Val 660 665 670 Met Asp Ile Ser Leu Pro Thr Gly
Ile Ser Ala Asn Glu Glu Asp Leu 675 680 685 Lys Ala Leu Val Glu Gly
Val Asp Gln Leu Phe Thr Asp Tyr Gln Ile 690 695 700 Lys Asp Gly His
Val Ile Leu Gln Leu Asn Ser Ile Pro Ser Ser Asp 705 710 715 720 Phe
Leu Cys Val Arg Phe Arg Ile Phe Glu Leu Phe Glu Val Gly Phe 725 730
735 Leu Ser Pro Ala Thr Phe Thr Val Tyr Glu Tyr His Arg Pro Asp Lys
740 745 750 Gln Cys Thr Met Phe Tyr Ser Thr Ser Asn Ile Lys Ile Gln
Lys Val 755 760 765 Cys Glu Gly Ala Ala Cys Lys Cys Val Glu Ala Asp
Cys Gly Gln Met 770 775 780 Gln Glu Glu Leu Asp Leu Thr Ile Ser Ala
Glu Thr Arg Lys Gln Thr 785 790
795 800 Ala Cys Lys Pro Glu Ile Ala Tyr Ala Tyr Lys Val Ser Ile Thr
Ser 805 810 815 Ile Thr Val Glu Asn Val Phe Val Lys Tyr Lys Ala Thr
Leu Leu Asp 820 825 830 Ile Tyr Lys Thr Gly Glu Ala Val Ala Glu Lys
Asp Ser Glu Ile Thr 835 840 845 Phe Ile Lys Lys Val Thr Cys Thr Asn
Ala Glu Leu Val Lys Gly Arg 850 855 860 Gln Tyr Leu Ile Met Gly Lys
Glu Ala Leu Gln Ile Lys Tyr Asn Phe 865 870 875 880 Ser Phe Arg Tyr
Ile Tyr Pro Leu Asp Ser Leu Thr Trp Ile Glu Tyr 885 890 895 Trp Pro
Arg Asp Thr Thr Cys Ser Ser Cys Gln Ala Phe Leu Ala Asn 900 905 910
Leu Asp Glu Phe Ala Glu Asp Ile Phe Leu Asn Gly Cys 915 920 925
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