U.S. patent application number 15/255508 was filed with the patent office on 2017-07-13 for methods for reducing exacerbation rates of asthma using benralizumab.
The applicant listed for this patent is ASTRAZENECA AB. Invention is credited to Donald Raible, Lorin Roskos, Bing Wang, Christine Ward.
Application Number | 20170198049 15/255508 |
Document ID | / |
Family ID | 52448837 |
Filed Date | 2017-07-13 |
United States Patent
Application |
20170198049 |
Kind Code |
A1 |
Ward; Christine ; et
al. |
July 13, 2017 |
METHODS FOR REDUCING EXACERBATION RATES OF ASTHMA USING
BENRALIZUMAB
Abstract
Provided herein is are methods of reducing exacerbations of
asthma in an asthma patient, comprising administering to the
patient an effective amount of the anti-interleukin-5 receptor
(IL-5R) antibody benralizumab or an antigen-binding fragment
thereof.
Inventors: |
Ward; Christine; (Richboro,
PA) ; Roskos; Lorin; (Gaithersburg, MD) ;
Wang; Bing; (Gaithersburg, MD) ; Raible; Donald;
(Berwyn, PA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
ASTRAZENECA AB |
SODERTALJE |
|
SE |
|
|
Family ID: |
52448837 |
Appl. No.: |
15/255508 |
Filed: |
September 2, 2016 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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14453942 |
Aug 7, 2014 |
9441037 |
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15255508 |
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61864944 |
Aug 12, 2013 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 39/395 20130101;
A61P 11/06 20180101; C07K 2317/76 20130101; C07K 2317/24 20130101;
A61K 2039/505 20130101; C07K 16/2866 20130101; A61K 2039/545
20130101; A61P 11/10 20180101; C07K 16/244 20130101 |
International
Class: |
C07K 16/28 20060101
C07K016/28 |
Claims
1. A method of reducing the annual exacerbation rate of asthma,
comprising administering to an asthma patient an effective amount
of benralizumab or an antigen-binding fragment thereof, wherein the
administration reduces the patient's exacerbation rate.
2. (canceled)
3. (canceled)
4. (canceled)
5. (canceled)
6. (canceled)
7. The method of claim 1, wherein the asthma is eosinophilic
asthma.
8. The method of claim 1, wherein the patient has a blood
eosinophil count of at least 300 cells/.mu.l.
9. The method of claim 1, wherein, the patient has a forced
expiratory volume (FEV.sub.1) of at least 75% predicted value prior
to the administration.
10. The method of claim 1, wherein the patient has an asthma
control questionnaire score of at least 1.5 prior to the
administration.
11. The method of claim 1, wherein at least two doses of
benralizumab or an antigen-binding fragment thereof are
administered to the patient.
12. (canceled)
13. The method of claim 1, wherein the annual exacerbation rate is
reduced by at least 35%.
14. (canceled)
15. The method of claim 13, wherein the annual exacerbation rate is
reduced by at least 50%.
16. The method of claim 15, wherein the annual exacerbation rate is
reduced by at least 60%.
17. The method of claim 1, wherein the patient uses high-dose
inhaled corticosteroids (ICS).
18. The method of claim 1, wherein the patient uses long-acting
.beta.2 agonists (LABA).
19. The method of claim 1, wherein the patient has a history of
exacerbations.
20. The method of claim 19, wherein the history of exacerbations
comprises at least two exacerbations in the year prior to the
administration of the benralizumab or antigen-binding fragment
thereof.
21. (canceled)
22. The method of claim 1, wherein the benralizumab or
antigen-binding fragment thereof is administered at about 2 mg to
about 100 mg per dose.
23. (canceled)
24. The method of claim 23, wherein the benralizumab or
antigen-binding fragment thereof is administered at about 30 mg per
dose.
25. (canceled)
26. The method of claim 1, wherein the benralizumab or
antigen-binding fragment thereof is administered once every four
weeks to once every twelve weeks.
27. (canceled)
28. (canceled)
29. The method of claim 26, wherein the benralizumab or
antigen-binding fragment thereof is administered once every four
weeks for twelve weeks and then once every eight weeks.
30. The method of claim 1, wherein the benralizumab or
antigen-binding fragment thereof is administered parenterally.
31. The method of claim 30, wherein the benralizumab or
antigen-binding fragment thereof is administered
subcutaneously.
32. The method of claim 1, wherein the benralizumab or
antigen-binding fragment thereof is administered in addition to
corticosteroid therapy.
33-48. (canceled)
Description
BACKGROUND
[0001] More than 300 million people around the world have asthma.
Despite the use of long-acting bronchodilators and inhaled
corticosteroids, unscheduled visits to doctor offices, visits to
emergency departments (ED), and hospitalizations due to asthma
exacerbations occur frequently and account for a significant
proportion of healthcare costs attributable to asthma. (Masoli M,
et al. Allergy 59: 469-78(2004)).
[0002] Relapse following acute asthma exacerbation has been
reported to range from 41 to 52% at 12 weeks despite the use of
systemic steroids upon discharge (Lederle F, et al. Arch Int Med
147:2201-03 (1987)). Management of these patients has proved
problematic due either to severe refractory disease or inability
and/or unwillingness to comply with medical treatment. In one study
of patients admitted to the hospital, some with near fatal asthma,
50% were non-compliant with systemic corticosteroids at 7 days
following discharge (Krishnan J, et al. AJRCCM 170: 1281-85
(2004)). Many factors may contribute to non-compliance including
poor access to routine quality healthcare (particularly in the
inner city), lack of education or understanding of their disease,
unwillingness to accept the chronic nature of their disease, or
inability to obtain medications.
[0003] Many lines of evidence implicate eosinophils as one of the
main causative cells of asthmatic airway inflammation (James A.
Curr Opin Pulm Med 11(1):1-6 (2005)). Peripheral blood (PB)
eosinophilia is a risk factor for relapse of acute asthma (Janson C
and Herala M. Resp Med 86(2):101-104 (1992)). In subjects with
peripheral blood eosinophilia, the risk of dying from asthma was
7.4 (confidence interval, 2.8-19.7) times greater than in those
without eosinophilia (Ulrik C and Fredericksen J. Chest 108:10-15
(1995)). Necropsy results have identified 2 distinct pathogenic
inflammatory mechanisms of fatal asthma (Restrepo R and Peters J.
Curr Opin Pulm Med 14: 13-23 (2008)). A neutrophilic infiltrate is
more prominent in those dying suddenly (approximately within 2
hours on onset of symptoms), while an eosinophilic infiltrate is
more common in those dying from more protracted asthma crises.
Sputum and blood eosinophils can also be increased in patients
presenting to the ED with rapid onset of asthma symptoms
(Bellido-Casado J, et al. Arch Bronconeumol 46(11): 587-93 (2010)).
Therapies that target eosinophils lead to a reduction in the number
and severity of asthma exacerbations as compared to the use of
clinical guidelines (Green R, et al. Lancet 360:1715-21 (2002);
Haldar P, et al. NEJM 360:973-84 (2009)).
[0004] Benralizumab (MEDI-563) is a humanized monoclonal antibody
(mAb) that binds to the alpha chain of the interleukin-5 receptor
alpha (IL-5R.alpha.), which is expressed on eosinophils and
basophils. It induces apoptosis of these cells via
antibody-dependent cell cytotoxicity. A single intravenous (IV)
dose of benralizumab administered to adults with mild asthma
provoked prolonged PB eosinopenia likely due to the effects on
eosinophil/basophil bone marrow progenitors that express the target
(Busse W, et al. JACI 125: 1237-1244 e2 (2010)). In addition, a
single dose of benralizumab significantly reduced the blood
eosinophil count in subjects who presented to the emergency
department with a severe asthma exacerbation (WO 2013/066780).
Benralizumab does not affect other cell lineages in the bone marrow
or periphery. (Kolbeck R, et al. JACI 125:1344-53 (2010)).
[0005] Previous studies have demonstrated that an outpatient
strategy focused on reducing eosinophils in the sputum reduces the
number of subsequent asthma exacerbations (Green R, et al. Lancet
360:1715-21 (2002); Haldar P, et al. NEJM 360:973-84 (2009)).
[0006] Thus, given the high unmet need of reducing exacerbations of
asthma and that some subjects with asthma have an eosinophilic
component, the effect of benralizumab on asthma exacerbation rates
in adult subjects was examined.
BRIEF SUMMARY
[0007] Methods of reducing the annual exacerbation rate of asthma
are provided herein. In certain aspects, a method of reducing the
annual exacerbation rate of asthma comprises administering to an
asthma patient an effective amount of benralizumab or an
antigen-binding fragment thereof.
[0008] Methods of treating asthma are also provided herein. In
certain aspects, a method of treating asthma comprises
administering to an asthma patient an effective amount of
benralizumab or an antigen-binding fragment thereof, wherein the
patient has a blood eosinophil count of at least 300 cells/.mu.l
prior to the administration.
[0009] In certain aspects, a method of treating asthma comprises
administering to an asthma patient an effective amount of
benralizumab or an antigen-binding fragment thereof, wherein the
patient has a forced expiratory volume (FEV.sub.1) of at least 75%
predicted value prior to the administration.
[0010] In certain aspects, a method of treating asthma comprises
administering at least two doses of benralizumab or an
antigen-binding fragment thereof to an asthma patient.
[0011] In certain aspects of the methods provided herein, the
administration reduces the patient's exacerbation rate. In certain
aspects, the administration reduces the patient's annual
exacerbation rate. In certain aspects, the annual exacerbations
rate following administration of benralizumab or an antigen-binding
fragment thereof is reduced by at least 35%. In certain aspects,
the annual exacerbation rate following administration of
benralizumab or an antigen-binding fragment thereof is reduced by
at least 40%. In certain aspects, the annual exacerbation rate
following administration of benralizumab or an antigen-binding
fragment thereof is reduced by at least 50%. In certain aspects,
the annual exacerbations rate following administration of
benralizumab or an antigen-binding fragment thereof is reduced by
at least 60%.
[0012] In certain aspects of the methods provided herein, the
asthma is eosinophilic asthma. In certain aspects, the patient has
a blood eosinophil count of at least 300 cells/.mu.l.
[0013] In certain aspects of the methods provided herein, the
patient has a forced expiratory volume (FEV.sub.1) of at least 75%
predicted value prior to the administration. In certain aspects,
the patient has an asthma control questionnaire score of at least
1.5 prior to the administration. In certain aspects, the patient
uses high-dose inhaled corticosteroids (ICS). In certain aspects,
the patient uses long-acting .beta.2 agonists (LABA). In certain
aspects, the patient has a history of exacerbations. In certain
aspects, the history of exacerbations comprises at least two
exacerbations in the year prior to the administration of
benralizumab or an antigen-binding fragment thereof. In certain
aspects, the history of exacerbations comprises no more than six
exacerbations in the year prior to the administration of
benralizumab or an antigen-binding fragment thereof.
[0014] In certain aspects of the methods provided herein, at least
two doses of benralizumab or an antigen-binding fragment thereof
are administered to the patient.
[0015] In certain aspects of the methods provided herein,
benralizumab or an antigen-binding fragment thereof is administered
at about 2 mg to about 100 mg per dose. In certain aspects,
benralizumab or an antigen-binding fragment thereof is administered
at about 20 mg per dose. In certain aspects, benralizumab or an
antigen-binding fragment thereof is administered at about 30 mg per
dose. In certain aspects, benralizumab or an antigen-binding
fragment thereof is administered at about 100 mg per dose.
[0016] In certain aspects of the methods provided herein,
benralizumab or an antigen-binding fragment thereof is administered
once every four weeks to once every twelve weeks. In certain
aspects, the benralizumab or antigen-binding fragment thereof is
administered once every four weeks. In certain aspects,
benralizumab or an antigen-binding fragment thereof is administered
once every eight weeks. In certain aspects, benralizumab or an
antigen-binding fragment thereof is administered once every four
weeks for twelve weeks and then once every eight weeks.
[0017] In certain aspects of the methods provided herein,
benralizumab or an antigen-binding fragment thereof is administered
parenterally. In certain aspects, benralizumab or an
antigen-binding fragment thereof is administered
subcutaneously.
[0018] In certain aspects of the methods provided herein,
benralizumab or an antigen-binding fragment thereof is administered
in addition to corticosteroid therapy.
[0019] In certain aspects, a method of reducing the annual
exacerbation rate of asthma comprises administering to an asthma
patient 20-100 mg of benralizumab or an antigen-binding fragment
thereof, wherein the patient has an blood eosinophil count of at
least 300 cells/.mu.l prior to the administration. In certain
aspects, the method comprises administering 20 mg of benralizumab
or an antigen-binding fragment thereof. In certain aspects, the 20
mg of benralizumab is administered once every four weeks for twelve
weeks and then once every eight weeks. In certain aspects, the
method comprises administering 30 mg of benralizumab or an
antigen-binding fragment thereof. In certain aspects, the 30 mg of
benralizumab is administered once every four weeks for eight weeks
and then once every eight weeks. In certain aspects, the 30 mg of
benralizumab is administered once every four weeks. In certain
aspects, the method comprises administering 100 mg of benralizumab
or an antigen-binding fragment thereof. In certain aspects, the 100
mg of benralizumab is administered once every four weeks for twelve
weeks and then once every eight weeks.
[0020] In certain aspects, a method of treating asthma in an asthma
patient comprises administering to the patient a dose of at least 2
and less than 100 mg of benralizumab or an antigen-binding fragment
thereof. In certain aspects, the method comprises administering 20
mg of benralizumab or an antigen-binding fragment. In certain
aspects, the method comprises administering 30 mg of benralizumab
or an antigen-binding fragment. In certain aspects, the method
comprises administering a dose of at least 20 and less than 100 mg
of benralizumab or an antigen-binding fragment. In certain aspects,
the method comprises administering a dose of at least 30 and less
than 100 mg of benralizumab or an antigen-binding fragment. In
certain aspects, the method decreases exacerbation rates of asthma.
In certain aspects, the method decreases annual exacerbation rates
of asthma. In certain aspects, the administration is
subcutaneous.
[0021] In certain aspects of the provided methods, administration
of benralizumab or an antigen-binding fragment thereof results in
the reduction in exacerbation rates as shown in FIGS. 2-8.
[0022] In certain aspects of the provided methods, administration
of benralizumab or an antigen-binding fragment thereof results in
the reduction in exacerbation rates as shown in Examples 1-2.
BRIEF DESCRIPTION OF THE DRAWINGS/FIGURES
[0023] FIG. 1 shows the study flow diagram.
[0024] FIG. 2 shows the interim (24 weeks) and annual (Stage I; 52
weeks) exacerbation rates after treatment with placebo, 2 mg
benralizumab, 20 mg benralizumab, or 100 mg benralizumab in
patients with fewer than 300 eosinophils/.mu.l and patients with at
least 300 eosinophils/.mu.l.
[0025] FIG. 3 shows the interim (24 weeks) and annual (Stage I; 52
weeks) exacerbation rates after treatment with placebo, 2 mg
benralizumab, 20 mg benralizumab, or 100 mg benralizumab in
patients with medium or high use of inhaled corticosteroids
(ICS).
[0026] FIG. 4 shows the interim (24 weeks) and annual (Stage I; 52
weeks) exacerbation rates after treatment with placebo, 2 mg
benralizumab, 20 mg benralizumab, or 100 mg benralizumab in
patients with fewer than 300 eosinophils/.mu.l and (i) medium use
of ICS or (ii) high use of ICS.
[0027] FIG. 5 shows the interim (24 weeks) and annual (Stage I; 52
weeks) exacerbation rates after treatment with placebo, 2 mg
benralizumab, 20 mg benralizumab, or 100 mg benralizumab in
patients with at least 300 eosinophils/.mu.l and (i) medium use of
ICS or (ii) high use of ICS.
[0028] FIG. 6 shows the annual exacerbation rates in patients with
fewer than 300 eosinophils/.mu.l and patients with at least 300
eosinophils/.mu.l.
[0029] FIGS. 7A and 7B show the number of exacerbations in patients
with various eosinophil counts.
[0030] FIG. 8 shows the time course of eosinophil depletion in
patients with at least 300 eosinophils/.mu.l.
DETAILED DESCRIPTION
[0031] It is to be noted that the term "a" or "an" entity refers to
one or more of that entity; for example, "an anti-IL-5.alpha.
antibody" is understood to represent one or more anti-IL-5.alpha.
antibodies. As such, the terms "a" (or "an"), "one or more," and
"at least one" can be used interchangeably herein.
[0032] Provided herein are methods for reducing exacerbations of
asthma. The methods provided include administering an effective
amount of benralizumab or an antigen-binding fragment thereof.
[0033] Information regarding benralizumab (or fragments thereof)
for use in the methods provided herein can be found in U.S. Patent
Application Publication No. US 2010/0291073 A1, the disclosure of
which is incorporated herein by reference in its entirety.
Benralizumab and antigen-binding fragments thereof for use in the
methods provided herein comprise a heavy chain and a light chain or
a heavy chain variable region and a light chain variable region. In
a further aspect, benralizumab or an antigen-binding fragment
thereof for use in the methods provided herein includes any one of
the amino acid sequences of SEQ ID NOs: 1-4. In a specific aspect,
benralizumab or an antigen-binding fragment thereof for use in the
methods provided herein comprises a light chain variable region
comprising the amino acid sequence of SEQ ID NO:1 and a heavy chain
variable region comprising the amino acid sequence of SEQ ID NO:3.
In a specific aspect, benralizumab or an antigen-binding fragment
thereof for use in the methods provided herein comprises a light
chain comprising the amino acid sequence of SEQ ID NO: 2 and heavy
chain comprising the amino acid sequence of SEQ ID NO:4. In a
specific aspect, benralizumab or an antigen-binding fragment
thereof for use in the methods provided herein comprises a heavy
chain variable region and a light chain variable region, wherein
the heavy chain variable region comprises the Kabat-defined CDR1,
CDR2, and CDR3 sequences of SEQ ID NOs: 7-9, and wherein the light
chain variable region comprises the Kabat-defined CDR1, CDR2, and
CDR3 sequences of SEQ ID NOs: 10-12. Those of ordinary skill in the
art would easily be able to identify Chothia-defined, Abm-defined
or other CDRs. In a specific aspect, benralizumab or an
antigen-binding fragment thereof for use in the methods provided
herein comprises the variable heavy chain and variable light chain
CDR sequences of the KM1259 antibody as disclosed in U.S. Pat. No.
6,018,032, which is herein incorporated by reference in its
entirety.
[0034] In certain aspects, a patient presenting at a physician's
office or ED with asthma is administered benralizumab or an
antigen-binding fragment thereof. Given the ability benralizumab to
reduce or deplete eosinophil counts for up to 12 weeks or more (see
US 2010/0291073), benralizumab or an antigen-binding fragment
thereof can be administered only once or infrequently while still
providing benefit to the patient in reducing exacerbations. In
further aspects the patient is administered additional follow-on
doses. Follow-on doses can be administered at various time
intervals depending on the patient's age, weight, ability to comply
with physician instructions, clinical assessment, eosinophil count
(blood or sputum eosinophils), Eosinophilic Cationic Protein (ECP)
measurement, Eosinophil-derived neurotoxin measurement (EDN), Major
Basic Protein (MBP) measurement and other factors, including the
judgment of the attending physician. The intervals between doses
can be every 4 weeks, every 5 weeks, every 6 weeks, every 8 weeks,
every 10 weeks, every 12 weeks, or longer intervals. In certain
aspects the intervals between doses can be every 4 weeks, every 8
weeks, or every 12 weeks. In certain aspects, the single dose or
first dose is administered to the asthma patient shortly after the
patient presents with an exacerbation, e.g., a mild, moderate or
severe exacerbation. For example, benralizumab or an
antigen-binding fragment thereof can be administered during a
presenting clinic or hospital visit, or in the case of very severe
exacerbations, within 1, 2, 3, 4, 5, 6, 7, or more days, e.g., 7
days of the acute exacerbation, allowing the patient's symptoms to
stabilize prior to administration of benralizumab.
[0035] In some embodiments, at least two doses of benralizumab or
an antigen-binding fragment thereof are administered to the
patient. In some embodiments, at least three doses, at least four
doses, at least five doses, at least six doses, or at least seven
doses are administered to the patient. In some embodiments,
benralizumab or an antigen-binding fragment thereof is administered
over the course of four weeks, over the course of eight weeks, over
the course of twelve weeks, over the course of twenty-four weeks,
or over the course of a year.
[0036] The amount of benralizumab or antigen-binding fragment
thereof to be administered to the patient will depend on various
parameters such as the patient's age, weight, clinical assessment,
eosinophil count (blood or sputum eosinophils), Eosinophilic
Cationic Protein (ECP) measurement, Eosinophil-derived neurotoxin
measurement (EDN), Major Basic Protein (MBP) measurement and other
factors, including the judgment of the attending physician. In
certain aspects, the dosage or dosage interval is not dependent on
the eosinophil level.
[0037] In certain aspects the patient is administered one or more
doses of benralizumab or an antigen-binding fragment thereof,
wherein the dose is about 2 mg to about 100 mg, for example about
20 mg to about 100 mg, or about 30 mg to about 100 mg. In certain
specific aspects, the patient is administered one or more doses of
benralizumab or an antigen-binding fragment thereof where the dose
is about 20 mg, about 30 mg, about 40 mg, about 50 mg, about 60 mg,
about 70 mg, about 80 mg, about 90 mg, or about 100 mg. In some
embodiments, the dose is about 20 mg. In some embodiments the dose
is about 30 mg. In some embodiments, the dose is about 100 mg.
[0038] In certain aspects, administration of benralizumab or an
antigen-binding fragment thereof according to the methods provided
herein is through parenteral administration. For example,
benralizumab or an antigen-binding fragment thereof can be
administered by intravenous infusion or by subcutaneous
injection.
[0039] In certain aspects, benralizumab or an antigen-binding
fragment thereof is administered according to the methods provided
herein in combination or in conjunction with additional asthma
therapies. Such therapies include, without limitation, inhaled
corticosteroid therapy, long- or short-term bronchodilator
treatment, oxygen supplementation, or other standard therapies as
described, e.g., in the National Asthma Education and Prevention
Program (NAEPP) Guidelines. In certain aspects, use of the methods
provided herein, i.e., administration of benralizumab or an
antigen-binding fragment thereof to an asthma patient with a
history of exacerbations serves as adjunct therapy in situations of
poor compliance with standard forms of asthma management.
[0040] The methods provided herein can significantly reduce
exacerbations of asthma. Reduction can be measured based on the
expected exacerbations predicted based on a large patient
population, or based on the individual patient's history of
exacerbations. In certain aspects, the patient population is those
patients who had .gtoreq.2 exacerbations requiring systemic
corticosteroid bursts in the past year. In certain aspects, the
patient population is those patients who had .gtoreq.2
exacerbations requiring systemic corticosteroid bursts in the past
year and .ltoreq.6 exacerbations requiring systemic corticosteroid
bursts in the past year. In certain aspects, the patient population
is patients having an eosinophil count of at least 300
cells/.mu.l.
[0041] In certain aspects, use of the methods provided herein,
i.e., administration of benralizumab or an antigen-binding fragment
thereof reduces the number of exacerbations experienced by the
patient over a 24-week period following administration of
benralizumab or an antigen-binding fragment thereof, as compared to
the number of exacerbations expected according to the patient's
history, as compared to the average number of exacerbations
expected in a comparable population of patients, or as compared to
a comparable population treated with placebo over the same time
period. In certain aspects, the patient can receive follow on doses
of benralizumab or an antigen-binding fragment thereof at periodic
intervals, e.g., every 4 weeks, every 5 weeks, every 6 weeks, every
8 weeks, every 12 weeks, or as scheduled based on patient's age,
weight, ability to comply with physician instructions, clinical
assessment, eosinophil count (blood or sputum eosinophils),
Eosinophilic Cationic Protein (ECP) measurement, Eosinophil-derived
neurotoxin measurement (EDN), Major Basic Protein (MBP) measurement
and other factors, including the judgment of the attending
physician. Use of the methods provided herein can reduce the
frequency of exacerbations by 10%, 20%, 30%, 35%, 40%, 45%, 50%,
55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95% or 100% over the
24-week period.
[0042] In other aspects, use of the methods provided herein, i.e.,
administration of benralizumab or an antigen-binding fragment
thereof to an asthma patient, reduces the number of exacerbations
experienced by the patient over a 52-week period (i.e., the annual
exacerbation rate) following administration of benralizumab or an
antigen-binding fragment thereof, as compared to the number of
exacerbations expected according to the patient's history, as
compared to the average number of exacerbations expected in a
comparable population of patients, or as compared to a comparable
population treated with placebo over the same time period. In
certain aspects, the patient can receive follow on doses of
benralizumab or an antigen-binding fragment thereof at periodic
intervals, e.g., every 4 weeks, every 5 weeks, every 6 weeks, every
8 weeks, every 12 weeks, or as scheduled based on patient's age,
weight, ability to comply with physician instructions, clinical
assessment, eosinophil count (blood or sputum eosinophils),
Eosinophilic Cationic Protein (ECP) measurement, Eosinophil-derived
neurotoxin measurement (EDN), Major Basic Protein (MBP) measurement
and other factors, including the judgment of the attending
physician. In certain aspects, the interval is every 4 weeks, every
8 weeks or every 12 weeks. Use of the methods provided herein can
reduce the annual exacerbations by 10%, 20%, 30%, 35%, 40%, 45%,
50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95% or 100%.
[0043] In certain aspects, use of the methods provided herein,
i.e., administration of benralizumab or an antigen-binding fragment
thereof to an asthma patient, reduces the annual exacerbation rate,
increases forced expiratory volume (FEV.sub.1), and/or improves an
asthma questionnaire score (e.g., the asthma control questionnaire
(ACQ)).
[0044] In certain aspects, the patient is "eosinophilic positive"
meaning the patient is one whose asthma is likely to be
eosinophilic.
[0045] In certain aspects, the asthma patient has a particular
blood eosinophil count, e.g., prior to the administration of
benralizumab or an antigen-binding fragment thereof. Blood
eosinophil counts can be measured, for example, using a complete
blood count (CBC) with cell differential.
[0046] In certain aspects, the asthma patient has a blood
eosinophil count of at least 300 cells/.mu.l prior to the
administration of benralizumab or an antigen-binding fragment
thereof. In certain aspects, the asthma patient has a blood
eosinophil count of at least 350 cells/.mu.l, at least 400
cells/.mu.l, at least 450 cells/.mu.l, or at least 500 cells/.mu.l
prior to the administration of benralizumab or an antigen-binding
fragment thereof.
[0047] In certain aspects, the asthma patient has a blood
eosinophil count of less than 300 cells/.mu.l prior to the
administration of benralizumab or an antigen-binding fragment
thereof. In certain aspects, the asthma patient has a blood
eosinophil count of at least 100 cells/.mu.l, at least 150
cells/.mu.l, at least 180 cells/.mu.l, at least 200 cells/.mu.l, or
at least 250 cells/.mu.l prior to the administration of
benralizumab or an antigen-binding fragment thereof.
[0048] In certain aspects, the asthma patient was prescribed or has
been using a medium-dose of inhaled corticosteroids (ICS) use prior
to the administration of benralizumab or an antigen-binding
fragment thereof. A medium-dose of ICS can be a dose of at least
600 .mu.g to 1,200 .mu.g budesonide daily or an equivalent dose of
another ICS.
[0049] In certain aspects, the asthma patient was prescribed or had
been using a high-dose of ICS use prior to the administration of
benralizumab or an antigen-binding fragment thereof. A high-dose of
ICS can be a dose of at least 1,200 .mu.g budesonide daily or an
equivalent dose of another ICS. A high dose of ICS can also be a
dose of greater than 1,200 .mu.g to 2000 .mu.g budesonide daily or
an equivalent dose of another ICS.
[0050] In certain aspects, the asthma patient was prescribed or has
been using oral corticosteroids prior to the administration of
benralizumab or an antigen-binding fragment thereof. In certain
aspects, administration of benralizumab or an antigen-binding
fragment thereof decreases the use of oral corticosteroids in an
asthma patient. In certain aspects, the administration decreases
the use of oral corticosteroids in an asthma patient by at least
50%.
[0051] In certain aspects, the asthma patient was prescribed or had
been using a long-acting beta agonist (LABA) prior to the
administration of benralizumab or an antigen-binding fragment
thereof.
[0052] In certain aspects, the asthma patient was prescribed or had
been using both ICS and LABA prior to the administration of
benralizumab or an antigen-binding fragment thereof.
[0053] In certain aspects, the asthma patient has a blood
eosinophil count of at least 300 cells/.mu.l and high ICS use prior
to the administration of benralizumab or an antigen-binding
fragment thereof.
[0054] In certain aspects, the asthma patient had a forced
expiratory volume in 1 second (FEV.sub.1) of at least 40% and less
than 90% predicted value prior to the administration of
benralizumab or an antigen-binding fragment thereof. In some
embodiments, the FEV.sub.1 was greater than 70% predicted value
prior to the administration of benralizumab or an antigen-binding
fragment thereof. In some embodiments, the FEV.sub.1 was greater
than 70% and less than 90% predicted value prior to the
administration of benralizumab or an antigen-binding fragment
thereof. In some embodiments, the FEV.sub.1 was at least 75%
predicted value prior to the administration of benralizumab or an
antigen-binding fragment thereof. In some embodiments, the
FEV.sub.1 was at least 75% and less than 90% prior predicted value
to the administration of benralizumab or an antigen-binding
fragment thereof. In some embodiments, the FEV.sub.1 was at least
80% predicted value prior to the administration of benralizumab or
an antigen-binding fragment thereof. In some embodiments, the
FEV.sub.1 was at least 80% and less than 90% predicted value prior
to the administration of benralizumab or an antigen-binding
fragment thereof.
EXAMPLES
Example 1: Patients and Methods
Subjects
[0055] Subjects in this study were required to be 18 to 75 years of
age with a weight of greater than 45 kg and less than or equal to
150 kg (greater than 100 pounds, but less than or equal to 330
pounds). They also must have had a physician diagnosis of asthma
for a minimum of 12 months prior to screening as well as physician
prescribed daily use of medium-dose or high-dose inhaled
corticosteroids (ICS) plus long-acting beta agonist (LABA) or any
combination of sequential dosing of either medium-dose or high-dose
ICS/LABA for at least 12 months prior to screening. Medium and
high-doses of ICS as defined in this study are shown in Table 1
below.
TABLE-US-00001 TABLE 1 Estimated Comparative Daily Dosages for
Inhaled Corticosteroids Medium Daily High Daily Drug Dose (Adult)
Dose (Adult) Beclamethazone HFA/MDI 40 or 80 .mu.g/puff >240-480
.mu.g >480 .mu.g Budesonide DPI 90, 180, or 200 .mu.g/inhalation
>600-1,200 .mu.g >1,200 .mu.g Ciclesonide HFA/MDI 80 or 160
.mu.g/inhalation >160-320 .mu.g >320-1280 .mu.g Flunisolide
CFC/MDI 250 .mu.g/puff >1,000-2,000 .mu.g >2,000 .mu.g
Flunisolide HFA/MDI 80 .mu.g/puff >320-640 .mu.g >640 .mu.g
Fluticasone HFA/MDI: 44, 110, or 220 .mu.g/puff >264-440 .mu.g
>440 .mu.g DPI: 50, 100, or 250 .mu.g/puff >300-500 .mu.g
>500 .mu.g Mometasone DPI 200 .mu.g/inhalation 400 .mu.g >400
.mu.g Triamcinolone acetonide CFC/MDI 75 .mu.g/puff >750-1,500
.mu.g >1,500 .mu.g CFC = chlorofluorocarbon; DPI = dry powder
inhaler; HFA = hydrofluoroalkane; MDI = metered dose inhaler.
[0056] The dose of other asthma controller medications must have
been stable in the subjects for at least 30 days prior to
screening. Subjects must also have had at least 2, but no more than
6, documented asthma exacerbations in the 12 months prior to
screening that required the use of a systemic corticosteroid burst.
Subjects must also have had a morning pre-bronchodilator forced
expiratory volume in 1 second (FEV.sub.1) of at least 40% and less
than 90% predicted during the screening/run-in period (described
below). Subjects must also have fulfilled one of the following
criteria: [0057] (a) Proof of post-bronchodilator reversibility of
airflow obstruction .gtoreq.12% and .gtoreq.200 mL documented
within 36 months prior to randomization or proof of a positive
response [PC20.ltoreq.8 mg/mL] to a methacholine challenge
documented within 36 months prior to randomization; OR [0058] (b) A
post-bronchodilator increase in FEV.sub.1.gtoreq.12% and
.gtoreq.200 mL at Week-3 screening visit; OR [0059] (c) If a) and
b) were not met and all other inclusion/exclusion criteria were
met, subjects with a FEV.sub.1 of .gtoreq.1.5 L and .gtoreq.60%
predicted on the Week-2 screening visit were eligible to undergo a
methacholine challenge at the Week-2 screening visit at sites where
methacholine testing was available. If the subject achieved a
positive response, (PC20.ltoreq.8 mg/mL), then this inclusion
criterion was met.
[0060] Subjects must also have had an Asthma Control Questionnaire
(ACQ) score of at least 1.5 at least twice during the
screening/run-in period.
[0061] Subjects were not able to participate if they had a
cigarette exposure of 10 pack-years or more or had been smoking
within 12 months prior to screening or had any condition (e.g., any
eosinophilic lower respiratory disease other than asthma, chronic
obstructive pulmonary disease (COPD), or cystic fibrosis) that, in
the opinion of the investigator or medical monitor, would interfere
with the evaluation. Subjects were also not able to participate if
they had received an oral corticosteroid burst or short-acting
systemic corticosteroid within 30 days prior to screening or during
the screening/run-in period.
Design of the Study
[0062] The study was a phase 2b randomized, double-blind,
placebo-controlled, dose-ranging, multicenter study
(ClinicalTrials.gov number: NCT01238861) in which multiple doses of
benralizumab were administered subcutaneously to asthma patients.
Benralizumab was administered at 2, 20, or 100 mg doses, and
patients were followed for 1 year. The study flow diagram is shown
in FIG. 1.
[0063] A 3-week screening/run-in period preceded administration of
benralizumab or placebo. During the 3-week period, subjects
continued to use the same medium-dose or high-dose ICS/LABA
combination product as prior to the participation in the study
(doses of ICS/LABA were required to be stable for 30 days prior to
the 3-week screening/run-in period). Subjects remained on the same
dose of ICS/LABA throughout the study.
[0064] The administered benralizumab composition contained
benralizumab (50 mg/mL), 10 mM histidine, 10 mM histidine HCl
monohydrate, 9% (w/v) trehalose dihydrate, and 0.004% (w/v)
polysorbate-20, pH 6. The administered placebo composition
contained 10 mM histidine, 10 mM histidine hydrochloride
monohydrate, 9% (w/v) trehalose dihydrate, and 0.02% (w/v)
polysorbate-20, pH 6.
[0065] Subjects received two subcutaneous (SC) injections of 1 ml
of benralizumab or placebo every four weeks for the first 3 doses
on Weeks 1 (Day 1), 4, and 8 and then every 8 weeks thereafter for
the last 4 doses on Weeks 16, 24, 32, and 40. After Week 40,
subjects were followed for an additional 12 weeks (through Week 52)
for assessment of acute exacerbations. The day of receipt of the
first dose of benralizumab or placebo was considered Day 1.
[0066] For the purpose of this study, an asthma exacerbation was
defined as a progressive increase of asthma symptoms (cough,
wheeze, chest tightness, and/or shortness of breath) that did not
resolve after the initiation of rescue medications and remained
troublesome for the subject resulting in either 1) use of systemic
corticosteroids (tablets, suspension or injection) or increase of a
stable systemic maintenance dose for a duration of at least 3 days
as prescribed or administered by the investigator or healthcare
provider; or 2) subject initiation of systemic corticosteroids for
a duration of at least 3 days. An asthma exacerbation event was
considered resolved 7 days after the last dose of oral
corticosteroid was administered (10 days after administration of an
injectable corticosteroid). Courses of corticosteroids initiated
after this time period were considered a separate new asthma
exacerbation. Asthma exacerbations were classified as "moderate" if
worsening symptoms required systemic corticosteroids or "severe" if
worsening symptoms required systemic corticosteroids and urgent
care evaluation and/or hospital admission.
[0067] Asthma exacerbations were assessed at weeks-3, -2, -1, 1 (on
Day 1 and Day 6), 4, 8, 12, 16, 20, 24, 28, 32, 36, 40, 46, and
52.
[0068] Annual exacerbation rate was defined as the number of
exacerbations from Week 1 (Day 1) to Week 52. If a subject
discontinued before the Week 52 visit, the annual exacerbation rate
for that subject was calculated according to the following formula:
observed number of asthma exacerbations/observed
Days.times.364.
[0069] Weighted mean rate of asthma exacerbations was estimated by
pooling all the asthma exacerbations in a treatment group and
dividing by the total follow-up time in that treatment group.
Safety Assessments
[0070] Adverse events were monitored following administration of
placebo or benralizumab. Other assessments included physical
examination, vital sign monitoring, and laboratory
measurements.
Example 2: Results
Enrollment and Baseline Characteristics
[0071] The baseline characteristics of all randomized subjects who
received any dose of investigational product are provided in Table
2 below. The mean population ICS dose was 1100 budesonide
equivalents overall, 700 budesonide equivalents in the medium dose
stratum, and 1600 budesonide equivalents in the high dose
stratum.
TABLE-US-00002 TABLE 2 Demographics for Baseline Eosinophils (EOS)
PLACEBO BENRALIZUMAB PLACEBO BENRALIZUMAB POPULATION EOS < 300
EOS < 300 EOS >= 300 EOS >= 300 N 139 151 83 232 Mean Age
(yrs) 50.3 51.2 45.2 46.3 Gender Female (%) 71 70 66 68 Race White
(%) 76 80 64 65 BMI (mean) 29.6 29.2 28.8 28.5 EOS mean cells/ul
149 156 542 548-615 Chronic OCS (%) 2.2% 7.9% 4.8% 4.3% FEV.sub.1
(L) % pred 70.0 54-69 65 64-67 Reversibility (%) 12.5 13-18 15.5
17-19 Historical 2.2 2.3-2.5 2.2 2.3-2.5 Exacerbations ACQ at
Baseline 2.5 2.5-2.8 2.6 2.4-2.7 Childhood 32% 33-38% 40% 37-41%
Asthma YES History Nasal 10.8% 11.9% 14.5% 19.3% Polyps YES
FE.sub.NO mean ppb 22.1 21-39 34.8 34-42 OCS = oral
corticosteroids; FEV.sub.1 = forced expiratory volume in 1 second;
ACQ = asthma control questionnaire; and FENO = fraction of exhaled
nitric oxide.
[0072] The baseline characteristics of randomized subjects who
received any dose of investigational product and had a baseline
eosinophil count of at least 300 cells/.mu.l are shown in Table 3
below.
TABLE-US-00003 TABLE 3 Demographics for ICS with Baseline EOS at
Least 300 Cells/.mu.l PLACEBO BENRALIZUMAB PLACEBO BENRALIZUMAB
POPULATION MED ICS MED ICS HIGH ICS HIGH ICS N 43 121 40 111 Mean
Age (yrs) 45 46-47 45 45-47 Gender Female (%) 65 63 68 70-79 Race
White (%) 56 66 73 63 BMI (mean) 27.3 27.6-28.3 30.3 27.8-30.0 EOS
mean cells/ul 480 462-625 608 605-656 Chronic OCS (%) 0 0 10% 9%
FEV.sub.1 (L) % pred 68.8 64-70 60 63-65 Reversibility (%) 16%
17-23% 15% 14-21% Historical 2.2 2.1-2.5 2.3 2.4-2.5 Exacerbations
ACQ at Baseline 2.6 2.3-2.6 2.7 2.6-2.8 Childhood 42% 36% 38%
27-53% Asthma YES History Nasal 14% 11% 15% 23-37% Polyps YES
FE.sub.NO mean ppb 38.3 35-45 31.0 33-39 OCS = oral
corticosteroids; FEV.sub.1 = forced expiratory volume in 1 second;
ACQ = asthma control questionnaire; and FENO = fraction of exhaled
nitric oxide.
Efficacy
[0073] The effects of administration of benralizumab on
exacerbation rates are shown in FIGS. 2-8. Only about 30% of the
subjects had exacerbations. In addition, administration of 20 mg or
100 mg of benralizumab significantly reduced (p<0.169) annual
exacerbation rates in asthma patients with a blood eosinophil count
of at least 300 cells/.mu.l and in asthma patients with both a
blood eosinophil count of at least 300 cells/.mu.l and a high
baseline ICS status.
[0074] In patients with a blood eosinophil count of at least 300
cells/.mu.l, administration of 20 mg of benralizumab reduced the
annual exacerbation rate by 57% (p=0.014), and administration of
100 mg of benralizumab reduced the annual exacerbation rate by 43%
(p=0.049) compared to treatment with placebo (FIG. 2).
[0075] In patients with a blood eosinophil count of at least 300
cells/.mu.l and a high baseline ICS status, administration of 20 mg
of benralizumab reduced the annual exacerbation rate by 52%
(p=0.118), and administration of 100 mg of benralizumab reduced the
annual exacerbation rate by 46% (p=0.102) compared to treatment
with placebo (FIG. 5).
[0076] Reductions in exacerbation rates were also observed in
patients with a blood eosinophil count of less than 300 cells/.mu.l
(FIGS. 2 and 4) as well as patients with a medium or high baseline
ICS (FIG. 3).
[0077] A comparison of the reduction in exacerbation rates in
patients with less than 300 cells/.mu.l and patients with at least
300 cells/.mu.l prior to treatment is shown in FIG. 6, and the
number of exacerbations at various eosinophil counts are provided
in FIG. 7.
[0078] In addition, eosinophils were reduced in patients receiving
any dose of benralizumab as compared to patients receiving placebo.
FIG. 8.
Safety
[0079] Treatment emergent adverse events (TEAEs) occurred at an
approximate 10 percentage point higher frequency in patients
treated with benralizumab compared with those treated with placebo.
Treatment emergent severe adverse events (TE-SAEs) occurred at
similar frequencies in patients treated with benralizumab and
placebo. TEAEs and TE-SAEs were not dose dependent in patients
treated with benralizumab.
Anti-Drug Antibodies
[0080] The development of anti-drug antibodies (ADA) to
benralizumab was inversely related to dose, with the highest
proportion of ADA-positive subjects at the 2 mg dose (see Table 4
below). The incidence of high titer ADA (.gtoreq.400) was 12% and
9% in the 20 and 100 mg dose groups, respectively. High titer ADAs
were associated with reduced benralizumab concentration and varying
degrees of eosinophil recovery when present. The
pharmacokinetic/pharmacodynamic (PK/PD) impact of high titer ADA
was reduced at higher drug exposures. No pattern was observed
between TEAEs and ADA.
TABLE-US-00004 TABLE 4 Anti-Drug Antibodies at Week 24 % Subjects %
Subjects Total Number with Positive with ADA Treatment Group of
Subjects ADA Titres Titres .gtoreq. 400 Placebo 222 8.1% (n = 18)
3% (n = 6) Benralizumab 2 mg 81 34.6% (n = 28) 23% (n = 19)
Benralizumab 20 mg 81 18.5% (n = 15) 12% (n = 10) Benralizumab 100
mg 222 21.2% (n = 47) 9% (n = 20)
[0081] Based on both PK and immunological considerations,
additional patients will receive dosing of 30 mg benralizumab. In
some patients, the 30 mg benralizumab dose will be administered
every four weeks. In some patients, the 30 mg benralizumab dose
will be administered once every four weeks for three doses and then
once every eight weeks thereafter.
Discussion
[0082] This study demonstrates that benralizumab reduced
exacerbations in eosinophilic asthma patients (i.e., patients with
a baseline blood eosinophil count of at least 300 cells/.mu.l) on
medium or high-dose ICS/LABA. In particular, benralizumab
significantly reduced exacerbation rates in asthma patients with
blood eosinophil counts of at least 300 cells/.mu.l as well as
patients with both a blood eosinophil counts of at least 300
cells/.mu.l and a high ICS status. In these patients, exacerbation
rates were reduced at both interim (24-week) and annual (52-week)
time points and in patients receiving either 20 mg or 100 mg of
benralizumab.
Example 3: Additional Dose Evaluation
[0083] Dose-efficacy modeling was performed to identify additional
doses of benralizumab that reduce annual exacerbation rates and are
safe and well tolerated. The modeling indicated that a dose of
about 30 mg is the minimum effective dose to produce 90% maximum
treatment effect. Therefore patients with uncontrolled asthma
receive subcutaneous injections of 30 mg of benralizumab or
placebo. The 30 mg doses are administered (i) every four weeks or
(ii) every four weeks for eight weeks (3 doses) and then every
eight weeks (i.e., every 8 weeks including an additional dose at
week 4). The number of exacerbations in patients receiving 30 mg
benralizumab is compared to the number of exacerbations in patients
receiving placebo in order to demonstrate that 30 mg doses of
benralizumab decrease annual exacerbation rates. In addition, the
number of exacerbations in patients with baseline blood eosinophil
count of at least 300 cells/.mu.l is analyzed in order to
demonstrate that 30 mg doses of benralizumab can be effective in
decrease annual exacerbation rates in such patients.
[0084] Those skilled in the art will recognize, or be able to
ascertain using no more than routine experimentation, many
equivalents to the specific aspects of the disclosure described
herein. Such equivalents are intended to be encompassed by the
following claims.
[0085] Various publications are cited herein, the disclosures of
which are incorporated by reference in their entireties.
[0086] Although the foregoing invention has been described in some
detail by way of illustration and example for purposes of clarity
of understanding, it will be obvious that certain changes and
modifications can be practiced within the scope of the appended
claims.
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DIQMTQSPSSLSASVGDRVTITCGTSEDIINYLNWYQQKPGKAPKLLIYH
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PLAPSSKSTSGGTAALGCLVKDYFPEPVTV
SWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSSLGTQTYICNVNHKP
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GPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHN
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Sequence CWU 1
1
121107PRTHomo sapiens 1Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu
Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Gly Thr
Ser Glu Asp Ile Ile Asn Tyr 20 25 30 Leu Asn Trp Tyr Gln Gln Lys
Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr His Thr Ser Arg
Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser
Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu
Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Gly Tyr Thr Leu Pro Tyr 85 90
95 Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 2214PRTHomo
sapiens 2Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser
Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Gly Thr Ser Glu Asp
Ile Ile Asn Tyr 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Lys
Ala Pro Lys Leu Leu Ile 35 40 45 Tyr His Thr Ser Arg Leu Gln Ser
Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp
Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala
Thr Tyr Tyr Cys Gln Gln Gly Tyr Thr Leu Pro Tyr 85 90 95 Thr Phe
Gly Gln Gly Thr Lys Val Glu Ile Lys Arg Thr Val Ala Ala 100 105 110
Pro Ser Val Phe Ile Phe Pro Pro Ser Asp Glu Gln Leu Lys Ser Gly 115
120 125 Thr Ala Ser Val Val Cys Leu Leu Asn Asn Phe Tyr Pro Arg Glu
Ala 130 135 140 Lys Val Gln Trp Lys Val Asp Asn Ala Leu Gln Ser Gly
Asn Ser Gln 145 150 155 160 Glu Ser Val Thr Glu Gln Asp Ser Lys Asp
Ser Thr Tyr Ser Leu Ser 165 170 175 Ser Thr Leu Thr Leu Ser Lys Ala
Asp Tyr Glu Lys His Lys Val Tyr 180 185 190 Ala Cys Glu Val Thr His
Gln Gly Leu Ser Ser Pro Val Thr Lys Ser 195 200 205 Phe Asn Arg Gly
Glu Cys 210 3121PRTHomo sapiens 3Glu Val Gln Leu Val Gln Ser Gly
Ala Glu Val Lys Lys Pro Gly Ala 1 5 10 15 Ser Val Lys Val Ser Cys
Lys Ala Ser Gly Tyr Thr Phe Thr Ser Tyr 20 25 30 Val Ile His Trp
Val Arg Gln Arg Pro Gly Gln Gly Leu Ala Trp Met 35 40 45 Gly Tyr
Ile Asn Pro Tyr Asn Asp Gly Thr Lys Tyr Asn Glu Arg Phe 50 55 60
Lys Gly Lys Val Thr Ile Thr Ser Asp Arg Ser Thr Ser Thr Val Tyr 65
70 75 80 Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr
Leu Cys 85 90 95 Gly Arg Glu Gly Ile Arg Tyr Tyr Gly Leu Leu Gly
Asp Tyr Trp Gly 100 105 110 Gln Gly Thr Leu Val Thr Val Ser Ser 115
120 4451PRTHomo sapiens 4Glu Val Gln Leu Val Gln Ser Gly Ala Glu
Val Lys Lys Pro Gly Ala 1 5 10 15 Ser Val Lys Val Ser Cys Lys Ala
Ser Gly Tyr Thr Phe Thr Ser Tyr 20 25 30 Val Ile His Trp Val Arg
Gln Arg Pro Gly Gln Gly Leu Ala Trp Met 35 40 45 Gly Tyr Ile Asn
Pro Tyr Asn Asp Gly Thr Lys Tyr Asn Glu Arg Phe 50 55 60 Lys Gly
Lys Val Thr Ile Thr Ser Asp Arg Ser Thr Ser Thr Val Tyr 65 70 75 80
Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr Leu Cys 85
90 95 Gly Arg Glu Gly Ile Arg Tyr Tyr Gly Leu Leu Gly Asp Tyr Trp
Gly 100 105 110 Gln Gly Thr Leu Val Thr Val Ser Ser Ala Ser Thr Lys
Gly Pro Ser 115 120 125 Val Phe Pro Leu Ala Pro Ser Ser Lys Ser Thr
Ser Gly Gly Thr Ala 130 135 140 Ala Leu Gly Cys Leu Val Lys Asp Tyr
Phe Pro Glu Pro Val Thr Val 145 150 155 160 Ser Trp Asn Ser Gly Ala
Leu Thr Ser Gly Val His Thr Phe Pro Ala 165 170 175 Val Leu Gln Ser
Ser Gly Leu Tyr Ser Leu Ser Ser Val Val Thr Val 180 185 190 Pro Ser
Ser Ser Leu Gly Thr Gln Thr Tyr Ile Cys Asn Val Asn His 195 200 205
Lys Pro Ser Asn Thr Lys Val Asp Lys Lys Val Glu Pro Lys Ser Cys 210
215 220 Asp Lys Thr His Thr Cys Pro Pro Cys Pro Ala Pro Glu Leu Leu
Gly 225 230 235 240 Gly Pro Ser Val Phe Leu Phe Pro Pro Lys Pro Lys
Asp Thr Leu Met 245 250 255 Ile Ser Arg Thr Pro Glu Val Thr Cys Val
Val Val Asp Val Ser His 260 265 270 Glu Asp Pro Glu Val Lys Phe Asn
Trp Tyr Val Asp Gly Val Glu Val 275 280 285 His Asn Ala Lys Thr Lys
Pro Arg Glu Glu Gln Tyr Asn Ser Thr Tyr 290 295 300 Arg Val Val Ser
Val Leu Thr Val Leu His Gln Asp Trp Leu Asn Gly 305 310 315 320 Lys
Glu Tyr Lys Cys Lys Val Ser Asn Lys Ala Leu Pro Ala Pro Ile 325 330
335 Glu Lys Thr Ile Ser Lys Ala Lys Gly Gln Pro Arg Glu Pro Gln Val
340 345 350 Tyr Thr Leu Pro Pro Ser Arg Asp Glu Leu Thr Lys Asn Gln
Val Ser 355 360 365 Leu Thr Cys Leu Val Lys Gly Phe Tyr Pro Ser Asp
Ile Ala Val Glu 370 375 380 Trp Glu Ser Asn Gly Gln Pro Glu Asn Asn
Tyr Lys Thr Thr Pro Pro 385 390 395 400 Val Leu Asp Ser Asp Gly Ser
Phe Phe Leu Tyr Ser Lys Leu Thr Val 405 410 415 Asp Lys Ser Arg Trp
Gln Gln Gly Asn Val Phe Ser Cys Ser Val Met 420 425 430 His Glu Ala
Leu His Asn His Tyr Thr Gln Lys Ser Leu Ser Leu Ser 435 440 445 Pro
Gly Lys 450 5400PRTHomo sapiens 5Asp Leu Leu Pro Asp Glu Lys Ile
Ser Leu Leu Pro Pro Val Asn Phe 1 5 10 15 Thr Ile Lys Val Thr Gly
Leu Ala Gln Val Leu Leu Gln Trp Lys Pro 20 25 30 Asn Pro Asp Gln
Glu Gln Arg Asn Val Asn Leu Glu Tyr Gln Val Lys 35 40 45 Ile Asn
Ala Pro Lys Glu Asp Asp Tyr Glu Thr Arg Ile Thr Glu Ser 50 55 60
Lys Cys Val Thr Ile Leu His Lys Gly Phe Ser Ala Ser Val Arg Thr 65
70 75 80 Ile Leu Gln Asn Asp His Ser Leu Leu Ala Ser Ser Trp Ala
Ser Ala 85 90 95 Glu Leu His Ala Pro Pro Gly Ser Pro Gly Thr Ser
Ile Val Asn Leu 100 105 110 Thr Cys Thr Thr Asn Thr Thr Glu Asp Asn
Tyr Ser Arg Leu Arg Ser 115 120 125 Tyr Gln Val Ser Leu His Cys Thr
Trp Leu Val Gly Thr Asp Ala Pro 130 135 140 Glu Asp Thr Gln Tyr Phe
Leu Tyr Tyr Arg Tyr Gly Ser Trp Thr Glu 145 150 155 160 Glu Cys Gln
Glu Tyr Ser Lys Asp Thr Leu Gly Arg Asn Ile Ala Cys 165 170 175 Trp
Phe Pro Arg Thr Phe Ile Leu Ser Lys Gly Arg Asp Trp Leu Ala 180 185
190 Val Leu Val Asn Gly Ser Ser Lys His Ser Ala Ile Arg Pro Phe Asp
195 200 205 Gln Leu Phe Ala Leu His Ala Ile Asp Gln Ile Asn Pro Pro
Leu Asn 210 215 220 Val Thr Ala Glu Ile Glu Gly Thr Arg Leu Ser Ile
Gln Trp Glu Lys 225 230 235 240 Pro Val Ser Ala Phe Pro Ile His Cys
Phe Asp Tyr Glu Val Lys Ile 245 250 255 His Asn Thr Arg Asn Gly Tyr
Leu Gln Ile Glu Lys Leu Met Thr Asn 260 265 270 Ala Phe Ile Ser Ile
Ile Asp Asp Leu Ser Lys Tyr Asp Val Gln Val 275 280 285 Arg Ala Ala
Val Ser Ser Met Cys Arg Glu Ala Gly Leu Trp Ser Glu 290 295 300 Trp
Ser Gln Pro Ile Tyr Val Gly Asn Asp Glu His Lys Pro Leu Arg 305 310
315 320 Glu Trp Phe Val Ile Val Ile Met Ala Thr Ile Cys Phe Ile Leu
Leu 325 330 335 Ile Leu Ser Leu Ile Cys Lys Ile Cys His Leu Trp Ile
Lys Leu Phe 340 345 350 Pro Pro Ile Pro Ala Pro Lys Ser Asn Ile Lys
Asp Leu Phe Val Thr 355 360 365 Thr Asn Tyr Glu Lys Ala Gly Ser Ser
Glu Thr Glu Ile Glu Val Ile 370 375 380 Cys Tyr Ile Glu Lys Pro Gly
Val Glu Thr Leu Glu Asp Ser Val Phe 385 390 395 400 6398PRTMus
musculus 6Asp Leu Leu Asn His Lys Lys Phe Leu Leu Leu Pro Pro Val
Asn Phe 1 5 10 15 Thr Ile Lys Ala Thr Gly Leu Ala Gln Val Leu Leu
His Trp Asp Pro 20 25 30 Asn Pro Asp Gln Glu Gln Arg His Val Asp
Leu Glu Tyr His Val Lys 35 40 45 Ile Asn Ala Pro Gln Glu Asp Glu
Tyr Asp Thr Arg Lys Thr Glu Ser 50 55 60 Lys Cys Val Thr Pro Leu
His Glu Gly Phe Ala Ala Ser Val Arg Thr 65 70 75 80 Ile Leu Lys Ser
Ser His Thr Thr Leu Ala Ser Ser Trp Val Ser Ala 85 90 95 Glu Leu
Lys Ala Pro Pro Gly Ser Pro Gly Thr Ser Val Thr Asn Leu 100 105 110
Thr Cys Thr Thr His Thr Val Val Ser Ser His Thr His Leu Arg Pro 115
120 125 Tyr Gln Val Ser Leu Arg Cys Thr Trp Leu Val Gly Lys Asp Ala
Pro 130 135 140 Glu Asp Thr Gln Tyr Phe Leu Tyr Tyr Arg Phe Gly Val
Leu Thr Glu 145 150 155 160 Lys Cys Gln Glu Tyr Ser Arg Asp Ala Leu
Asn Arg Asn Thr Ala Cys 165 170 175 Trp Phe Pro Arg Thr Phe Ile Asn
Ser Lys Gly Phe Glu Gln Leu Ala 180 185 190 Val His Ile Asn Gly Ser
Ser Lys Arg Ala Ala Ile Lys Pro Phe Asp 195 200 205 Gln Leu Phe Ser
Pro Leu Ala Ile Asp Gln Val Asn Pro Pro Arg Asn 210 215 220 Val Thr
Val Glu Ile Glu Ser Asn Ser Leu Tyr Ile Gln Trp Glu Lys 225 230 235
240 Pro Leu Ser Ala Phe Pro Asp His Cys Phe Asn Tyr Glu Leu Lys Ile
245 250 255 Tyr Asn Thr Lys Asn Gly His Ile Gln Lys Glu Lys Leu Ile
Ala Asn 260 265 270 Lys Phe Ile Ser Lys Ile Asp Asp Val Ser Thr Tyr
Ser Ile Gln Val 275 280 285 Arg Ala Ala Val Ser Ser Pro Cys Arg Met
Pro Gly Arg Trp Gly Glu 290 295 300 Trp Ser Gln Pro Ile Tyr Val Gly
Lys Glu Arg Lys Ser Leu Val Glu 305 310 315 320 Trp His Leu Ile Val
Leu Pro Thr Ala Ala Cys Phe Val Leu Leu Ile 325 330 335 Phe Ser Leu
Ile Cys Arg Val Cys His Leu Trp Thr Arg Leu Phe Pro 340 345 350 Pro
Val Pro Ala Pro Lys Ser Asn Ile Lys Asp Leu Pro Val Val Thr 355 360
365 Glu Tyr Glu Lys Pro Ser Asn Glu Thr Lys Ile Glu Val Val His Cys
370 375 380 Val Glu Glu Val Gly Phe Glu Val Met Gly Asn Ser Thr Phe
385 390 395 75PRTHomo sapiens 7Ser Tyr Val Ile His 1 5 817PRTHomo
sapiens 8Tyr Ile Asn Pro Tyr Asn Asp Gly Thr Lys Tyr Asn Glu Arg
Phe Lys 1 5 10 15 Gly 912PRTHomo sapiens 9Glu Gly Ile Arg Tyr Tyr
Gly Leu Leu Gly Asp Tyr 1 5 10 1011PRTHomo sapiens 10Gly Thr Ser
Glu Asp Ile Ile Asn Tyr Leu Asn 1 5 10 117PRTHomo sapiens 11His Thr
Ser Arg Leu Gln Ser 1 5 129PRTHomo sapiens 12Gln Gln Gly Tyr Thr
Leu Pro Tyr Thr 1 5
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