U.S. patent application number 15/595890 was filed with the patent office on 2017-11-30 for methods for treatment of refractory generalized myasthenia gravis.
The applicant listed for this patent is ALEXION PHARMACEUTICALS, INC.. Invention is credited to Camille Bedrosian, Fanny O'Brien, Jing Jing Wang.
Application Number | 20170342139 15/595890 |
Document ID | / |
Family ID | 60412593 |
Filed Date | 2017-11-30 |
United States Patent
Application |
20170342139 |
Kind Code |
A1 |
Bedrosian; Camille ; et
al. |
November 30, 2017 |
Methods for Treatment of Refractory Generalized Myasthenia
Gravis
Abstract
The disclosure provides methods of treating myasthenia gravis
(MG) in a subject in need thereof by administering to the subject a
substance that specifically binds complement component 5 (C5). In
certain embodiments, the substance that specifically binds C5 is a
binding protein, such as an anti-C5 antibody.
Inventors: |
Bedrosian; Camille;
(Woodbridge, IL) ; O'Brien; Fanny; (Norwell,
MA) ; Wang; Jing Jing; (Woodbridge, CT) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
ALEXION PHARMACEUTICALS, INC. |
New Haven |
CT |
US |
|
|
Family ID: |
60412593 |
Appl. No.: |
15/595890 |
Filed: |
May 15, 2017 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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62342321 |
May 27, 2016 |
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62346168 |
Jun 6, 2016 |
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62489240 |
Apr 24, 2017 |
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62500643 |
May 3, 2017 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 2039/55 20130101;
A61P 43/00 20180101; C07K 16/18 20130101; A61K 2039/505 20130101;
A61M 1/3496 20130101; A61K 2039/54 20130101; C07K 2317/24 20130101;
A61K 2039/545 20130101; A61P 21/04 20180101 |
International
Class: |
C07K 16/18 20060101
C07K016/18; A61M 1/34 20060101 A61M001/34 |
Claims
1. A method of treating refractory generalized myasthenia gravis in
a patient in need thereof comprising administering a
therapeutically effective amount of eculizumab to the patient;
wherein the patient is positive for auto-antibodies binding to
nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) and requires chronic plasma exchange or chronic IVIg to
maintain clinical stability; and wherein the patient is
administered eculizumab for at least 26 weeks.
2. The method of claim 1, wherein eculizumab is administered using
a phased dosing schedule with an induction phase comprising
administering a 900 mg induction dose of eculizumab on day 1,
administering 900 mg doses of eculizumab on days 7, 14, and 21, and
administering 1200 mg of eculizumab as a fifth induction dose on
day 28; and wherein the patient is administered eculizumab for at
least 26 weeks.
3. The method of claim 2, wherein the 28 day induction phase of
eculizumab treatment is followed by a maintenance phase comprising
administering 1200 mg of eculizumab 14 days after the fifth
induction dose and administering 1200 mg of eculizumab every
14.+-.2 days thereafter.
4. The method of claim 3, further comprising performing
plasmapheresis on the patient and administering eculizumab at a
dose of between 300 mg and 1200 mg to the patient within 4 hours of
completion of plasmapheresis.
5. The method of claim 3, further comprising performing
plasmapheresis on the patient and administering eculizumab at a
dose of between 600 mg and 900 mg to the patient within 90 minutes
of completion of plasmapheresis.
6. The method of claim 3, further comprising performing
plasmapheresis on the patient and administering eculizumab at a
dose of 600 mg to the patient within 1 hour of completion of
plasmapheresis.
7. The method of claim 1, wherein the patient experiences a
clinically meaningful improvement (reduction) in Myasthenia Gravis
Activities of Daily Living (MG-ADL) score after 26 weeks of
treatment.
8. The method of claim 7, wherein the clinically meaningful
improvement the patient experiences is at least a 3 point reduction
in the patient's MG-ADL score after 26 weeks of treatment.
9. The method of claim 1, wherein the patient experiences a
clinically meaningful improvement (reduction) in quantitative
Myasthenia Gravis score (QMG) after 26 weeks of treatment.
10. The method of claim 9, wherein the clinically meaningful
improvement the patient experiences is at least a 4 point reduction
in the patient's QMG score after 26 weeks of treatment.
11. The method of claim 1, wherein the patient experiences a
clinically meaningful improvement (reduction) in Myasthenia Gravis
Composite (MGC) score after 26 weeks of treatment.
12. The method of claim 11, wherein the clinically meaningful
improvement the patient experiences is at least a 6 point reduction
in the patient's MGC score after 26 weeks of treatment.
13. The method of claim 1, wherein the patient experiences a
clinically meaningful improvement (reduction) in quality of life as
measured by Myasthenia Gravis Quality of Life (MG-QOL-15) score
after 26 weeks of treatment.
14. The method of claim 13, wherein the clinically meaningful
improvement the patient experiences is at least a 6 point reduction
in the patient's MG-QOL-15 score after 26 weeks of treatment.
15. The method of claim 1, wherein the patient experiences a
clinically meaningful improvement (reduction) in neuro-fatigue as
measured by Neuro-QOL Fatigue score after 26 weeks of
treatment.
16. The method of claim 15, wherein the clinically meaningful
improvement the patient experiences is at least an 8 point
reduction in the patient's Neuro-QOL score after 26 weeks of
treatment.
17. The method of claim 1, wherein the patient experiences a
clinically meaningful improvement (increase) in health status as
measured by EQ-5D health status score after 26 weeks of
treatment.
18. A method of treating refractory generalized myasthenia gravis
in a patient in need thereof comprising administering eculizumab to
the patient; wherein the patient is positive for auto-antibodies
binding to nicotinic acetylcholine receptor (anti-AChR) and shows
marked generalized weakness or bulbar signs and symptoms of
myasthenia gravis while receiving therapy for myasthenia gravis
including anticholinesterase inhibitor therapy and
immunosuppressant therapy (IST) and requires chronic plasma
exchange or chronic IVIg to maintain clinical stability; wherein
eculizumab is administered using a phased dosing schedule with an
induction phase comprising administering a 900 mg induction dose of
eculizumab on day 1, administering 900 mg doses of eculizumab on
days 7, 14, and 21, and administering 1200 mg of eculizumab as a
fifth induction dose on day 28; wherein the patient is administered
eculizumab for at least 26 weeks; wherein the 28 day induction
phase of eculizumab treatment is followed by a maintenance phase
comprising administering 1200 mg of eculizumab 14 days after the
fifth induction dose and administering 1200 mg of eculizumab every
14.+-.2 days thereafter; and wherein the patient has a clinically
meaningful improvement (reduction) in at least two measurements of
generalized myasthenia gravis severity selected from the group
consisting of MG-ADL, QMG, MGC, MG-QOL, and Neuro-QOL.
19. A method of treating refractory generalized myasthenia gravis
in a patient in need thereof comprising administering eculizumab to
the patient; wherein the patient is positive for auto-antibodies
binding to nicotinic acetylcholine receptor (anti-AChR) and shows
marked generalized weakness or bulbar signs and symptoms of
myasthenia gravis while receiving therapy for myasthenia gravis
including anticholinesterase inhibitor therapy and
immunosuppressant therapy (IST) and requires chronic plasma
exchange or chronic IVIg to maintain clinical stability; wherein
eculizumab is administered using a phased dosing schedule with an
induction phase comprising administering a 900 mg induction dose of
eculizumab on day 1, administering 900 mg doses of eculizumab on
days 7, 14, and 21, and administering 1200 mg of eculizumab as a
fifth induction dose on day 28; wherein the patient is administered
eculizumab for at least 26 weeks; wherein the 28 day induction
phase of eculizumab treatment is followed by a maintenance phase
comprising administering 1200 mg of eculizumab 14 days after the
fifth induction dose and administering 1200 mg of eculizumab every
14.+-.2 days thereafter; and wherein the patient has a clinically
meaningful improvement (reduction) in five measurements of
generalized myasthenia gravis severity, wherein the five
measurements of generalized myasthenia gravis severity are a
reduction in MG-ADL of at least 3 points, a reduction of QMG of at
least 4 points, a reduction in MGC of at least 6 points, a
reduction in MG-QOL of at least 6 points, and a reduction in
Neuro-QOL of at least 8 points.
20. The method of claim 19, wherein the patient has a clinically
meaningful improvement (reduction) in five measurements of
generalized myasthenia gravis, wherein the five measurements of
generalized myasthenia gravis severity are a reduction in MG-ADL of
at least 4 points, a reduction of QMG of at least 5 points, a
reduction in MGC of at least 10 points, a reduction in MG-QOL of at
least 11 points, and a reduction in Neuro-QOL of at least 16
points.
21. The method of claim 1, wherein eculizumab is administered by
intravenous infusion.
22. The method of claim 1, wherein eculizumab is administered
subcutaneously.
23. The method of claim 1, wherein the eculizumab comprises a heavy
chain amino acid sequence according to SEQ ID NO: 10 and a light
chain amino acid sequence according to SEQ ID NO: 11.
24. The method of claim 1, wherein the eculizumab is an eculizumab
variant comprising a heavy chain amino acid sequence according to
SEQ ID NO: 14 and a light chain amino acid sequence according to
SEQ ID NO: 11.
25. The method of claim 1, wherein the patient has failed treatment
over one year or more with two or more ISTs in sequence or in
combination.
26. The method of claim 1, wherein the patient has failed at least
one IST and requires chronic plasma exchange or IVIg to control
symptoms.
27. The method of claim 1, wherein the therapeutically effective
amount of eculizumab is maintained at a concentration of between
50-100 .mu.g/mL in the patient's serum.
28. The method of claim 1, wherein the patient experiences a
reduction in the administration of one or more IST following at
least 26 weeks of treatment.
29. The method of claim 1, wherein the patient experiences a
reduction in IST dosing following at least 26 weeks of
treatment.
30. The method of claim 1, wherein the patient experiences a
reduction in one or more IST dosing and a discontinuation in one or
more IST following at least 26 of treatment.
Description
BACKGROUND
[0001] Myasthenia Gravis (MG) is a rare, debilitating, acquired
autoimmune neurologic disorder of the neuromuscular junction (NMJ)
caused by the failure of neuromuscular transmission, which results
from the binding of auto-antibodies (Abs) to proteins involved in
signaling at the NMJ. These proteins include the nicotine
acetylcholine receptors (AChRs) or, less frequently, a
muscle-specific tyrosine kinase (MuSK) involved in AChR
clustering.
[0002] MG has a prevalence of 14-20 per 100,000 in the U.S.,
affecting roughly 60,000 Americans. It affects males and females in
equal ratio, although the incidence in females peaks in the 3rd
decade as compared to males in whom the peak age at onset is in the
6th or 7th decade. Mortality from MG is approximately 4%, mostly
due to respiratory failure.
[0003] Myasthenia gravis is clinically characterized by weakness
and fatigability of voluntary skeletal muscles. MG may initially
present with ocular muscle weakness affecting eye and eyelid
movement, referred to as ocular MG (oMG). Ten percent of subjects
have disease limited to ocular muscles. Ninety percent of subjects
have generalized MG, with muscle weakness involving neck, head,
spine, bulbar, respiratory, or limb muscles. Bulbar weakness refers
to muscles controlled by nerves originating from the bulb-like part
of the brainstem and manifests as difficulty in talking, chewing,
swallowing, and control of the head. MG may cause life-threatening
respiratory failure, referred to as myasthenic crisis. About 15% to
20% of subjects will experience a myasthenic crisis during the
course of their disease, 75% within 2 years of diagnosis, requiring
hospitalization and ventilatory support.
[0004] While there is no cure for MG, there are a variety of
therapies that reduce muscle weakness and improve neuromuscular
function. Current available treatments for myasthenia gravis aim to
modulate neuromuscular transmission, inhibit the production or
effects of pathogenic antibodies, or inhibit inflammatory
cytokines. There is currently no specific treatment that targets
the underlying pathophysiology of NMJ injury specifically:
anti-AChR antibody-AChR interactions resulting in complement
activation via the classical pathway and inflammation, with the
resultant destruction of the NMJ. There is no specific treatment
that corrects the autoimmune defect in MG. With immunosuppressive
therapies (ISTs) the current standard of care, which usually
combines cholinesterase inhibitors, corticosteroids and
immunosuppressive drugs (most commonly azathioprine [AZA],
cyclosporin, and mycophenolate mofetil [MMF]), the majority of
subjects with MG have their disease reasonably well controlled.
However, there is a cohort of refractory subjects who do not
respond adequately to ISTs, or cannot tolerate ISTs, and those who
require repeated treatments with plasma exchange (PE) and/or
intravenous immunoglobulin (IVIg) to maintain clinical stability.
For these subjects, an alternative therapy is needed.
SUMMARY
[0005] This disclosure provides methods of treating refractory
generalized myasthenia gravis in a patient in need thereof
comprising administering a therapeutically effective amount of an
anti-complement component 5 (C5) antibody or an antigen binding
fragment thereof to the patient, wherein the patient is
administered the anti-C5 antibody or antigen binding fragment
thereof for at least 26 weeks.
[0006] In certain embodiments, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering a therapeutically effective
amount of an anti-C5 antibody or an antigen binding fragment
thereof to the patient, wherein the anti-C5 antibody, or an antigen
binding fragment thereof is eculizumab or an eculizumab variant and
wherein the patient is administered eculizumab or eculizumab
variant for at least 26 weeks.
[0007] In another embodiment, this disclosure provides a method
comprising administering a therapeutically effective amount of
eculizumab to a patient, wherein the patient is positive for
auto-antibodies binding to nicotinic acetylcholine receptor
(anti-AChR) and shows marked generalized weakness or bulbar signs
and symptoms of myasthenia gravis while receiving therapy for
myasthenia gravis including anticholinesterase inhibitor therapy
and immunosuppressant therapy (IST) and requires chronic plasma
exchange or chronic IVIg to maintain clinical stability; and
wherein the patient is administered eculizumab for at least 26
weeks.
[0008] In one embodiment, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering eculizumab to the patient,
wherein the patient is positive for auto-antibodies binding to
nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) and had previously failed treatment with at least two
immunosuppressive agents or failed treatment with at least one
immunosuppressive agent and required chronic plasma exchange or
IVIg, and had an MG-ADL total score .gtoreq.6 at study entry;
wherein eculizumab is administered using a phased dosing schedule
with an induction phase comprising administering a 900 mg induction
dose of eculizumab on day 1, administering 900 mg doses of
eculizumab on days 7, 14, and 21, and administering 1200 mg as a
fifth induction dose on day 28, wherein the patient is administered
eculizumab for at least 26 weeks; wherein the 28 day induction
phase of eculizumab treatment is followed by a maintenance phase
comprising administering 1200 mg of eculizumab 14 days after the
fifth induction dose and administering 1200 mg of eculizumab every
14.+-.2 days thereafter, and wherein the patient has a clinically
meaningful improvement (reduction) in two measurements of
generalized myasthenia gravis severity selected from the group
consisting of MG-ADL, QMG, and MGC.
[0009] In a particular embodiment, this disclosure provides a
method of treating refractory generalized myasthenia gravis in a
patient in need thereof comprising administering eculizumab to the
patient, wherein the patient is positive for auto-antibodies
binding to nicotinic acetylcholine receptor (anti-AChR) and shows
marked generalized weakness or bulbar signs and symptoms of
myasthenia gravis while receiving therapy for myasthenia gravis
including anticholinesterase inhibitor therapy and
immunosuppressant therapy (IST) or requires chronic plasma exchange
or chronic IVIg to maintain clinical stability; wherein eculizumab
is administered using a phased dosing schedule with an induction
phase comprising administering a 900 mg induction dose of
eculizumab on day 1, administering 900 mg doses of eculizumab on
days 7, 14, and 21, and administering 1200 mg of eculizumab as a
fifth induction dose on day 28, and wherein the patient is
administered eculizumab for at least 26 weeks.
[0010] In a further embodiment, this disclosure provides a method
wherein the 28 day induction phase of eculizumab treatment is
followed by a maintenance phase comprising administering 1200 mg of
eculizumab 14 days after the fifth induction dose and 1200 mg of
eculizumab every 14.+-.2 days thereafter.
[0011] In certain embodiments, this disclosure provides a method
wherein the dosing regimen further comprises a third phase and
wherein the third phase comprises performing plasmapheresis on the
patient and administering eculizumab at a dose of between 300 and
1200 mg to the patient within 4 hours of completion of
plasmapheresis. In other embodiments, the third phase comprises
performing plasmapheresis on the patient and administering
eculizumab at a dose of between 600 and 900 mg to the patient
within 90 minutes of completion of plasmapheresis. In yet other
embodiments, the third phase comprises performing plasmapheresis on
the patient and administering eculizumab at a dose of 600 mg to the
patient within 1 hour of completion of plasmapheresis.
[0012] In one embodiment, the patient being treated by the methods
provided herein experiences a clinically meaningful improvement
(reduction) in Myasthenia Gravis Activities of Daily Living
(MG-ADL) score after 26 weeks of treatment. In a particular
embodiment, the clinically meaningful improvement the patient
experiences is at least a 3 point reduction in the patient's MG-ADL
score after 26 weeks of treatment. In another embodiment, the
clinically meaningful improvement the patient experiences is at
least a 4 point reduction in the patient's MG-ADL score after 26
weeks of treatment.
[0013] In another embodiment, the patient being treated by the
methods provided herein experiences a clinically meaningful
improvement (reduction) in quantitative Myasthenia Gravis score
(QMG) after 26 weeks of treatment. In a particular embodiment, the
clinically meaningful improvement the patient experiences is at
least a 4 point reduction in the patient's QMG score after 26 weeks
of treatment. In another embodiment, the clinically meaningful
improvement the patient experiences is a 5 point reduction in the
patient's QMG score after 26 weeks of treatment.
[0014] In another embodiment, the patient being treated by the
methods provided herein experiences a clinically meaningful
improvement (reduction) in Myasthenia Gravis Composite (MGC) score
after 26 weeks of treatment. In a particular embodiment, the
clinically meaningful improvement the patient experiences is at
least a 6 point reduction in the patient's MGC score after 26 weeks
of treatment. In another embodiment, the clinically meaningful
improvement the patient experiences is at least a 10 point
reduction in the patient's MGC score after 26 weeks of
treatment.
[0015] In another embodiment, the patient being treated by the
methods provided herein experiences a clinically meaningful
improvement (reduction) in quality of life as measured by the
Myasthenia Gravis Quality of Life (MG-QOL-15) score after 26 weeks
of treatment. In a particular embodiment, the clinically meaningful
improvement the patient experiences is at least a 6 point reduction
in the patient's MG-QOL-15 score after 26 weeks of treatment. In
another embodiment, the clinically meaningful improvement the
patient experiences is at least an 11 point reduction in the
patient's MG-QOL-15 score after 26 weeks of treatment.
[0016] In another embodiment, the patient being treated by the
methods provided herein experiences a clinically meaningful
improvement (reduction) in neuro-fatigue as measured by the
Neuro-QOL Fatigue score after 26 weeks of treatment. In a
particular embodiment, the clinically meaningful improvement the
patient experiences is at least an 8 point reduction in the
patient's Neuro-QOL score after 26 weeks of treatment. In another
embodiment, the clinically meaningful improvement the patient
experiences is at least a 16 point reduction in the patient's
Neuro-QOL score after 26 weeks of treatment.
[0017] In a certain embodiment, the patient being treated by the
methods provided herein experiences a clinically meaningful
improvement (increase) in health status as measured by the EQ-5D
health status score after 26 weeks of treatment.
[0018] In a particular embodiment, this disclosure provides a
method of treating refractory generalized myasthenia gravis in a
patient in need thereof comprising administering eculizumab to the
patient, wherein the patient is positive for auto-antibodies
binding to nicotinic acetylcholine receptor (anti-AChR) and shows
marked generalized weakness or bulbar signs and symptoms of
myasthenia gravis while receiving therapy for myasthenia gravis
including anticholinesterase inhibitor therapy and
immunosuppressant therapy (IST) or requires chronic plasma exchange
or chronic IVIg to maintain clinical stability; wherein eculizumab
is administered using a phased dosing schedule comprising
administering a 900 mg induction dose of eculizumab on day 1,
administering 900 mg doses of eculizumab on days 7, 14, and 21, and
administering 1200 mg of eculizumab as a fifth dose on day 28,
wherein the patient is administered eculizumab for at least 26
weeks; wherein the 28 day induction phase of eculizumab treatment
is followed by a maintenance phase comprising administering 1200 mg
of eculizumab 14 days after the fifth induction dose and
administering 1200 mg of eculizumab every 14.+-.2 days thereafter,
and wherein the patient has a clinically meaningful improvement
(reduction) in at least one measurement of generalized myasthenia
gravis severity selected from the group consisting of MG-ADL, QMG,
MGC, MG-QOL, and Neuro-QOL.
[0019] In another embodiment, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering eculizumab to the patient,
wherein the patient is positive for auto-antibodies binding to
nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) and requires chronic plasma exchange or chronic IVIg to
maintain clinical stability; wherein eculizumab is administered
using a phased dosing schedule comprising administering a 900 mg
induction dose on day 1, administering 900 mg doses of eculizumab
on days 7, 14, and 21, and administering 1200 mg of eculizumab as a
fifth dose on day 28, wherein the patient is administered
eculizumab for at least 26 weeks; wherein the 28 induction phase of
eculizumab treatment is followed by a maintenance phase comprising
administering 1200 mg of eculizumab 14 days after the fifth
induction dose and administering 1200 mg of eculizumab every
14.+-.2 days thereafter, and wherein the patient has a clinically
meaningful improvement (reduction) in two measurements of
generalized myasthenia gravis severity selected from the group
consisting of MG-ADL, QMG, MGC, MG-QOL, and Neuro-QOL.
[0020] In another embodiment, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering eculizumab to the patient,
wherein the patient is positive for auto-antibodies binding to
nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) or requires chronic plasma exchange or chronic IVIg to
maintain clinical stability; wherein eculizumab is administered
using a phased dosing schedule comprising administering a 900 mg
induction dose on day 1, administering 900 mg doses of eculizumab
on days 7, 14, and 21, and administering 1200 mg as a fifth dose on
day 28, wherein the patient is administered eculizumab for at least
26 weeks; wherein the 28 day induction phase of eculizumab
treatment is followed by a maintenance phase comprising
administering 1200 mg of eculizumab 14 days after the fifth
induction dose and administering 1200 mg of eculizumab every
14.+-.2 days thereafter, and wherein the patient has a clinically
meaningful improvement (reduction) in three measurements of
generalized myasthenia gravis severity selected from the group
consisting of MG-ADL, QMG, MGC, MG-QOL, and Neuro-QOL. In certain
embodiments, the patient has a clinically meaningful improvement
(reduction) in four measurements of generalized myasthenia gravis
severity selected from the group consisting of MG-ADL, QMG, MGC,
MG-QOL, and Neuro-QOL. In another embodiment, the patient has a
clinically meaningful improvement (reduction) in five measurements
of generalized myasthenia gravis severity, wherein the five
measurements of generalized myasthenia gravis severity are MG-ADL,
QMG, MGC, MG-QOL, and Neuro-QOL.
[0021] In another embodiment, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering eculizumab to the patient,
wherein the patient is positive for auto-antibodies binding to
nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) or requires chronic plasma exchange or chronic IVIg to
maintain clinical stability; wherein eculizumab is administered
using a phased dosing schedule comprising administering a 900 mg
induction dose on day 1, administering 900 mg doses of eculizumab
on days 7, 14, and 21, and administering 1200 mg as a fifth dose on
day 28, wherein the patient is administered eculizumab for at least
26 weeks; wherein the 28 day induction phase of eculizumab
treatment is followed by a maintenance phase comprising
administering 1200 mg of eculizumab 14 days after the fifth
induction dose and administering 1200 mg every 14.+-.2 days
thereafter, and wherein the patient has a clinically meaningful
improvement (reduction) in five measurements of generalized
myasthenia gravis severity, wherein the five measurements of
generalized myasthenia gravis severity are a reduction in MG-ADL of
at least 3 points, a reduction in QMG of at least 4 points, a
reduction in MGC of at least 6 points, a reduction in MG-QOL of at
least 6 points, and a reduction in Neuro-QOL of at least 8 points.
In certain embodiments, the patient has a clinically meaningful
improvement (reduction) in five measurements of generalized
myasthenia gravis severity, wherein the five measurements of
generalized myasthenia gravis severity are a reduction in MG-ADL of
at least 4 points, a reduction in QMG of at least 5 points, a
reduction in MGC of at least 10 points, a reduction in MG-QOL of at
least 11 points, and a reduction in Neuro-QOL of at least 16
points.
[0022] In a further embodiment, this disclosure provides a method
of treating refractory generalized myasthenia gravis in a patient
in need thereof comprising administering eculizumab by intravenous
infusion. In another embodiment, eculizumab is administered
subcutaneously. In another embodiment, the eculizumab comprises a
heavy chain amino acid sequence according to SEQ ID NO: 10 and a
light chain amino acid sequence according to SEQ ID NO: 11. In yet
another embodiment, the eculizumab is an eculizumab variant
comprising a heavy chain amino acid sequence according to SEQ ID
NO: 14 and a light chain amino acid sequence according to SEQ ID
NO: 11. In certain embodiments, the eculizumab is an eculizumab
variant comprising a heavy chain variable region amino acid
sequence according to SEQ ID NO: 12 and a light chain amino acid
sequence according to SEQ ID NO: 11.
[0023] In yet another embodiment, this disclosure provides a method
of treating refractory generalized myasthenia gravis in a patient
in need thereof comprising administering an anti-C5 antibody, or
antigen binding fragment thereof, wherein the antibody is an
anti-C5 antibody or an antigen binding fragment thereof comprising
a heavy chain variable region amino acid sequence according to SEQ
ID NO: 27 and a light chain variable region amino acid sequence
according to SEQ ID NO: 28. In yet another embodiment, the antibody
is an anti-C5 antibody or an antigen binding fragment thereof
comprising a heavy chain variable region amino acid sequence
according to SEQ ID NO: 35 and a light chain variable region amino
acid sequence according to SEQ ID NO: 36. In yet another
embodiment, the antibody is an anti-C5 antibody or antigen binding
fragment thereof comprising a heavy chain variable region amino
acid sequence according to SEQ ID NO: 37 and a light chain variable
region amino acid sequence according to SEQ ID NO: 38.
[0024] In one embodiment, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering an anti-C5 antibody or
antigen binding fragment thereof, wherein the patient has failed
treatment over one year or more with two or more ISTs in sequence
or in combination.
[0025] In one embodiment, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering an anti-C5 antibody or
antigen binding fragment thereof, wherein the patient has failed at
least one IST and requires chronic plasma exchange or IVIg to
control symptoms of myasthenia gravis.
[0026] In one embodiment, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering a therapeutically effective
amount of eculizumab is maintained at a concentration of between
50-100 pg/mL in the patient's serum.
[0027] In one embodiment, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering a therapeutically effective
amount of eculizumab, wherein the patient experiences a
discontinuation in the administration of one or more IST following
at least 26 weeks of treatment.
[0028] In one embodiment, this disclosure provides a method of
treating refractory generalized myasthenia gravis in a patient in
need thereof comprising administering a therapeutically effective
amount of eculizumab, wherein the patient experiences a reduction
in IST dosing following at least 26 weeks of treatment.
BRIEF DESCRIPTION OF THE DRAWINGS
[0029] FIG. 1 is a schematic of the overall design of the clinical
trial disclosed herein.
[0030] FIGS. 2A and 2B are a schematic of the EUROQOL (EQ-5D)
survey of health status questionnaire used in the clinical trial
disclosed herein.
[0031] FIG. 3 is a schematic of the N. meningitidis vaccination
schedule used in the clinical trial disclosed herein.
[0032] FIG. 4 is a schematic of the dosing schedule used in the
clinical trial disclosed herein.
[0033] FIG. 5 is a schematic of the dosing, clinical evaluation and
safety follow-up schedule, used in the clinical trial disclosed
herein.
[0034] FIG. 6 is a schematic of the dosing schedule used in the
clinical trial also including the extension period disclosed
herein.
[0035] FIG. 7 is a graphical depiction of the changes from baseline
in MG-ADL values obtained for placebo and eculizumab groups over
the initial 26 weeks of the trial.
[0036] FIG. 8 is a graphical depiction of the changes from baseline
in QMG values obtained for placebo and eculizumab groups over the
initial 26 weeks of the trial.
[0037] FIG. 9 is a graphical depiction of the changes from baseline
in MGC values obtained for placebo and eculizumab groups over the
initial 26 weeks of the trial.
[0038] FIG. 10 is a graphical depiction of the changes from
baseline in MG-QOL 15 values obtained for placebo and eculizumab
groups over the initial 26 weeks of the trial.
[0039] FIG. 11 is a graphical depiction of the numbers of patients
in both the placebo and eculizumab treated groups achieving between
a 5 and 10 point reduction in QMG score over the initial 26 weeks
of the trial.
[0040] FIG. 12 is a schematic of the REGAIN study design.
[0041] FIG. 13 is a graphical depiction of responder analyses
(MG-ADL and QMG) illustrating the proportion of patients with
improvement in total score and no rescue therapy at week 26 from
baseline.
[0042] FIG. 14 is a graphical depiction of the proportion of
patients with a .gtoreq.3, .gtoreq.5, or .gtoreq.8-point reduction
in MG-ADL total score and no rescue therapy over time from baseline
to week 26.
[0043] FIG. 15 is a graphical depiction of the proportion of
patients with .gtoreq.5, .gtoreq.7, or .gtoreq.10-point reduction
in QMG total score and no rescue over time from baseline to week
26.
[0044] FIG. 16 is a graphical depiction of dual responders
(assessed by MG-ADL and QMG total scores) with no rescue therapy at
week 26.
[0045] FIG. 17 is a graphical depiction of the proportion of
patients with at least 3-point improvement in MG-ADL total score
and .gtoreq.5-point improvement in QMG total score and no rescue
therapy assessed over time from baseline to week 26.
[0046] FIG. 18 is a graphical depiction of the percentage of
patients who simultaneously met increasingly stringent criteria
based on MG-ADL and QMG. The bottom row describes a threshold for
both scales above the MCID (minimal clinically meaningful
difference: 3 for MG-ADL and 5 for QMG). Higher bars represent
increasing thresholds. The right-most panel displays odds ratios
for meeting each threshold for eculizumab vs. placebo treated
patients.
[0047] FIG. 19 is a graphical depiction of the change from baseline
in MG-ADL total score (LS Mean and 95% CI) by treatment arm over
time from ECU-MG-302 baseline to week 52 in study ECU-MG-302 using
a repeated-measures model.
[0048] FIG. 20 is a graphical depiction of the change from baseline
in MG-ADL total score (Mean and 95% CI) by treatment arm over time
from ECU-MG-301 baseline to week 52 in study ECU-MG-302.
DETAILED DESCRIPTION
[0049] The disclosure provides methods of treating myasthenia
gravis (MG) in subjects or patients in need thereof by
administering an antibody that specifically binds complement
component 5 (C5). In certain embodiments, the antibody that
specifically binds C5 reduces the rate at which C5 is cleaved, in
vivo, into C5a and C5b. In other embodiments, the antibody that
specifically binds C5, binds to one or both of the C5a and/or C5b
fragments. In any of these embodiments, the antibody that
specifically binds C5 blocks the complement cascade at C5, thereby
reducing the release of proinflammatory mediators such as C5a and
the formation of a C5b-9 Membrane Attack Complex (MAC).
[0050] In certain embodiments, the antibody that specifically binds
C5 is eculizumab. In more specific embodiments, eculizumab is an
antibody or a fragment thereof.
[0051] Eculizumab (h5G1.1-mAb) is a humanized monoclonal antibody
(mAb) that was derived from the murine anti-human C5 antibody
m5G1.1. Eculizumab specifically binds the terminal complement
protein C5, thereby inhibiting its cleavage to C5a and C5b during
complement activation. This strategic blockade of the complement
cascade at C5 prevents the release of proinflammatory mediators and
the formation of the Membrane Attack Complex or cytolytic pore,
while preserving the early components of complement activation that
are essential for the opsonization of microorganisms and clearance
of immune complexes.
[0052] C5 binding proteins are described in U.S. Pat. No.
6,355,245, which is hereby incorporated herein by reference in its
entirety. In certain embodiments, the anti-C5 antibody is a
monoclonal antibody having a hybrid IgG2/4 isotype. In other
embodiments, the anti-C5 antibodies are effective in reducing the
cell-lysing ability of complement present in human blood. This
property of the antibodies can be determined by methods well known
in the art such as, for example, by the chicken erythrocyte
hemolysis method described in U.S. Pat. No. 6,355,245.
[0053] In certain embodiments, anti-C5 antibodies bind to C5 or
fragments thereof, e.g., C5a or C5b. In other embodiments, the
anti-C5 antibodies recognize and bind epitopes on either the alpha
chain or the beta chain of purified human complement component C5
and are capable of blocking the conversion of C5 into C5a and C5b
by C5 convertase. See Wurzner et al., Complement. Inflamm. 8(5-6):
328-40 (1991).
[0054] In other embodiments, the anti-C5 antibodies recognize and
bind epitopes within the alpha chain of purified human complement
component C5. In this embodiment, the antibodies are capable of
blocking the conversion of C5 into C5a and C5b by C5 convertase. In
one example of this embodiment, the antibodies can provide this
blockade at substantially the same concentrations needed to block
hemolytic activity.
[0055] In some embodiments, the antibodies specifically bind to an
amino-terminal region within the alpha chain, however, they do not
specifically bind to free C5a. In certain embodiments, the C5
antibody is able to substantially inhibit complement hemolytic
activity and to substantially inhibit the conversion of C5 to
produce C5a. In some embodiments, the C5 antibodies provide these
functions when used at a molar ratio of antibody to antigen (C5) of
3:1 or less.
[0056] As used herein, the term "antibodies" refers to
immunoglobulins produced in vivo, as well as those produced in
vitro by a hybridoma, and antigen binding fragments (e.g., Fab'
preparations) of such immunoglobulins, as well as to recombinantly
expressed antibodies or antigen binding proteins, including
immunoglobulins, chimeric immunoglobulins, "humanized"
immunoglobulins, antigen binding fragments of such immunoglobulins,
single chain antibodies, and other recombinant proteins containing
antigen binding domains derived from immunoglobulins such as DVD-Ig
and CODV-Ig. See U.S. Pat. Nos. 7,161,181 and 9,181,349.
"Specificity" refers to the ability of a binding protein to
selectively recognize and bind an antigen at a particular location
or structure, known as an epitope, often found on the surface of
the antigen.
[0057] The term "specifically binds," means that a binding protein
or fragment thereof forms a complex with an antigen that is
relatively stable under physiologic conditions. Specific binding
can be characterized by a dissociation constant of at least about
1.times.10.sup.-6 M or smaller. In other embodiments, the
dissociation constant is at least about 1.times.10.sup.-7 M,
1.times.10.sup.-8 M, 1.times.10.sup.-9 M, or
1.times.10.sup.-1.degree. M. Methods for determining whether two
molecules specifically bind are well known in the art and include,
for example, equilibrium dialysis, surface plasmon resonance, and
the like.
[0058] The anti-C5 antibodies described herein bind to complement
component C5 (e.g., human C5) and inhibit the cleavage of C5 into
fragments C5a and C5b. Anti-C5 antibodies (or VH/VL domains derived
therefrom) suitable for use in the invention can be generated using
methods known in the art.
[0059] An exemplary anti-C5 antibody is eculizumab comprising heavy
and light chains having the sequences shown in SEQ ID NOs: 10 and
11, respectively, or antigen binding fragments and variants
thereof. Eculizumab (also known as SOLIRIS.RTM.) is described in
U.S. Pat. No. 6,355,245. Eculizumab is a humanized monoclonal
antibody that is a terminal complement inhibitor.
[0060] In other embodiments, the antibody comprises the heavy and
light chain complementarity determining regions (CDRs) or variable
regions of eculizumab. Accordingly, in one embodiment, the antibody
comprises the CDR1, CDR2, and CDR3 domains of the VH region of
eculizumab having the sequence set forth in SEQ ID NO: 7, and the
CDR1, CDR2, and CDR3 domains of the VL region of eculizumab having
the sequence set forth in SEQ ID NO: 8. In another embodiment, the
antibody comprises heavy chain CDR1, CDR2, and CDR3 domains having
the sequences set forth in SEQ ID NOs: 1, 2, and 3, respectively,
and light chain CDR1, CDR2, and CDR3 domains having the sequences
set forth in SEQ ID NOs: 4, 5, and 6, respectively. In another
embodiment, the antibody comprises VH and VL regions having the
amino acid sequences set forth in SEQ ID NO: 7 and SEQ ID NO: 8,
respectively.
[0061] Empirical data indicate that serum eculizumab concentrations
greater than 50 .mu.g/mL and closer to at least 100 .mu.g/mL are
required to significantly reduce free C5 concentrations.
Specifically, free C5 concentration was reduced significantly with
increasing concentrations of eculizumab beginning at >50
.mu.g/mL and was at near zero levels with eculizumab concentrations
above 100 .mu.g/ml. Thus, in various embodiments, the method
comprises administering a therapeutically effective amount of
eculizumab to the subject, wherein the therapeutically effective
amount of eculizumab is maintained at a concentration of at least
50 .mu.g/mL of eculizumab in serum of the subject. In another
embodiment, the method comprises administering a therapeutically
effective amount of eculizumab to the subject, wherein the
therapeutically effective amount of eculizumab is maintained at a
concentration of at least 60 .mu.g/mL of eculizumab in serum of the
subject. In one embodiment, the method comprises administering a
therapeutically effective amount of eculizumab to the subject,
wherein the therapeutically effective amount of eculizumab is
maintained at a concentration of at least 70 .mu.g/mL of eculizumab
in serum of the subject. In another embodiment, the method
comprises administering a therapeutically effective amount of
eculizumab to the subject, wherein the therapeutically effective
amount of eculizumab is maintained at a concentration of at least
80 .mu.g/mL of eculizumab in serum of the subject. In another
embodiment, the method comprises administering a therapeutically
effective amount of eculizumab to the subject, wherein the
therapeutically effective amount of eculizumab is maintained at a
concentration of at least 90 .mu.g/mL of eculizumab in serum of the
subject. In another embodiment, the method comprises administering
a therapeutically effective amount of eculizumab to the subject,
wherein the therapeutically effective amount of eculizumab is
maintained at a concentration of at least 100 .mu.g/mL of
eculizumab in serum of the subject.
[0062] Another exemplary anti-C5 antibody is an eculizumab variant,
known as antibody BNJ441, and engineered to have a longer half-life
(T1/2) in humans comprising heavy and light chains having the
sequences shown in SEQ ID NOs: 14 and 11, respectively, or antigen
binding fragments and variants thereof. BNJ441 (also known as
ALXN1210) is described in International Publication No. WO
2015/134894 A1 and U.S. Pat. No. 9,079,949, the teachings or which
are hereby incorporated by reference. BNJ441 is a humanized
monoclonal antibody that is structurally related to eculizumab
(SOURIS.RTM.). BNJ441 selectively binds to human complement protein
C5, inhibiting its cleavage to C5a and C5b during complement
activation. This inhibition prevents the release of the
proinflammatory mediator C5a and the formation of the cytolytic
pore-forming membrane attack complex C5b-9 while preserving the
proximal or early components of complement activation (e.g., C3 and
C3b) essential for the opsonization of microorganisms and clearance
of immune complexes.
[0063] In other embodiments, the antibody comprises the heavy and
light chain CDRs or variable regions of BNJ441. Accordingly, in one
embodiment, the antibody comprises the CDR1, CDR2, and CDR3 domains
of the VH region of BNJ441 having the sequence set forth in SEQ ID
NO: 12, and the CDR1, CDR2, and CDR3 domains of the VL region of
BNJ441 having the sequence set forth in SEQ ID NO: 8. In another
embodiment, the antibody comprises heavy chain CDR1, CDR2, and CDR3
domains having the sequences set forth in SEQ ID NOs: 19, 18, and
3, respectively, and light chain CDR1, CDR2, and CDR3 domains
having the sequences set forth in SEQ ID NOs: 4, 5, and 6,
respectively. In another embodiment, the antibody comprises VH and
VL regions having the amino acid sequences set forth in SEQ ID NO:
12 and SEQ ID NO: 8, respectively. In another embodiment, the
antibody may comprise the heavy chain constant region of BNJ441
having the amino acid sequence set forth in SEQ ID NO: 13.
[0064] In various embodiments, eculizumab is administered in a
multiphase dosing regimen. For example, the multiphase dosing
regimen comprises a first phase and a second phase in various
embodiments. In certain embodiments, the first phase is an
induction phase and comprises administration of eculizumab at
between 900 mg once a week to the subject for between 1-10 weeks.
The induction phase is concluded by administering the first
maintenance phase dose of 1200 mg one week after the last 900 mg
dose.
[0065] In other embodiments, the second phase is a maintenance
phase and comprises administration of eculizumab at between 1000
and 1400 mg once every two weeks to the subject for 2 weeks, 4
weeks, 6 weeks, 8 weeks, 12, weeks, 26 weeks, or as long as
myasthenia gravis persists. In other embodiments, the maintenance
phase comprises administration of eculizumab at between 1000 and
1400 mg once every two weeks to the subject for 2 months, 4 months,
6 months, 8 months, 12 months, 2 years, three years, 4 years, 5
years, or for the remaining lifetime of the patient. In other
embodiments, the maintenance phase comprises administration of
eculizumab at about 1200 mg twice a month (biweekly) once the
induction phase is complete.
[0066] In another embodiment, the method comprises administering a
therapeutically effective amount of eculizumab or an eculizumab
variant to the subject, wherein the therapeutically effective
amount of eculizumab or eculizumab variant is maintained at a
concentration of between 50-100 .mu.g/mL, between 60-100 .mu.g/mL,
between 70-100 .mu.g/mL, between 80-100 .mu.g/mL, or between 90-100
.mu.g/mL of eculizumab in serum of the subject.
[0067] Another exemplary anti-C5 antibody is antibody BNJ421
comprising heavy and light chains having the sequences shown in SEQ
ID NOs: 20 and 11, respectively, or antigen binding fragments and
variants thereof. BNJ421 (also known as ALXN1211) is described in
International Publication No. WO 2015/134894 A1 and U.S. Pat. No.
9,079,949, the teachings or which are hereby incorporated by
reference.
[0068] In other embodiments, the antibody comprises the heavy and
light chain CDRs or variable regions of BNJ421. Accordingly, in one
embodiment, the antibody comprises the CDR1, CDR2, and CDR3 domains
of the VH region of BNJ421 having the sequence set forth in SEQ ID
NO: 12, and the CDR1, CDR2, and CDR3 domains of the VL region of
BNJ421 having the sequence set forth in SEQ ID NO: 8. In another
embodiment, the antibody comprises heavy chain CDR1, CDR2, and CDR3
domains having the sequences set forth in SEQ ID NOs: 19, 18, and
3, respectively, and light chain CDR1, CDR2, and CDR3 domains
having the sequences set forth in SEQ ID NOs: 4, 5, and 6,
respectively. In another embodiment, the antibody comprises VH and
VL regions having the amino acid sequences set forth in SEQ ID NO:
12 and SEQ ID NO: 8, respectively. In another embodiment, the
antibody may comprise the heavy chain constant region of BNJ421
having the amino acid sequence set forth in SEQ ID NO: 9.
[0069] Another exemplary anti-C5 antibody is the 7086 antibody
described in U.S. Pat. Nos. 8,241,628 and 8,883,158. In one
embodiment, the antibody may comprise the heavy and light chain
CDRs or variable regions of the 7086 antibody. See U.S. Pat. Nos.
8,241,628 and 8,883,158. In another embodiment, the antibody, or a
fragment thereof, may comprise heavy chain CDR1, CDR2, and CDR3
domains having the sequences set forth in SEQ ID NOs: 21, 22, and
23, respectively, and light chain CDR1, CDR2, and CDR3 domains
having the sequences set forth in SEQ ID NOs: 24, 25, and 26,
respectively. In another embodiment, the antibody or fragment
thereof may comprise the VH region of the 7086 antibody having the
sequence set forth in SEQ ID NO: 27, and the VL region of the 7086
antibody having the sequence set forth in SEQ ID NO: 28.
[0070] Another exemplary anti-C5 antibody is the 8110 antibody also
described in U.S. Pat. Nos. 8,241,628 and 8,883,158. In one
embodiment, the antibody may comprise the heavy and light chain
CDRs or variable regions of the 8110 antibody. The antibody, or
fragment thereof may comprise heavy chain CDR1, CDR2, and CDR3
domains having the sequences set forth in SEQ ID NOs: 29, 30, and
31, respectively, and light chain CDR1, CDR2, and CDR3 domains
having the sequences set forth in SEQ ID NOs: 32, 33, and 34,
respectively. In another embodiment, the antibody may comprise the
VH region of the 8110 antibody having the sequence set forth in SEQ
ID NO: 35, and the VL region of the 8110 antibody having the
sequence set forth in SEQ ID NO: 36.
[0071] Another exemplary anti-C5 antibody comprises a heavy chain
variable region amino acid sequence according to SEQ ID NO: 37 and
a light chain variable region amino acid sequence according to SEQ
ID NO: 38.
[0072] In various embodiments, eculizumab, an eculizumab variant
such as BNJ441, or other anti-C5 antibody is administered to the
subject once a month, once every two months, or once every three
months depending on the dose. In another embodiment, the
eculizumab, eculizumab variant such as BNJ441, or other anti-C5
antibody is administered once every two weeks, once a week, twice a
week, or three times a week. In other embodiments, eculizumab,
eculizumab variant such as BNJ441, or other anti-C5 antibody is
administered once a week, once every two weeks, once every three
weeks, once every four weeks, once every five weeks, once every six
weeks, or once every eight weeks depending on the needs of the
patient. In certain embodiments, eculizumab, eculizumab variant
such as BNJ441, or other anti-C5 antibody in administered
intravenously (IV) or subcutaneously (SubQ).
[0073] Also, provided herein are pharmaceutical compositions
comprising an anti-C5 antibody or antigen binding fragment thereof
with a pharmaceutically acceptable excipient for treating MG. In
one embodiment, the composition comprises an antibody comprising
the CDR1, CDR2, and CDR3 domains of the VH region of eculizumab
having the sequence set forth in SEQ ID NO: 7, and the CDR1, CDR2,
and CDR3 domains of the VL region of eculizumab having the sequence
set forth in SEQ ID NO: 8. In another embodiment, the antibody
comprises heavy chain CDR1, CDR2, and CDR3 domains having the
sequences set forth in SEQ ID NOs: 1, 2, and 3, respectively, and
light chain CDR1, CDR2, and CDR3 domains having the sequences set
forth in SEQ ID NOs: 4, 5, and 6, respectively. In another
embodiment, the antibody comprises VH and VL regions having the
amino acid sequences set forth in SEQ ID NO: 7 and SEQ ID NO: 8,
respectively.
[0074] In some embodiment, the antibody comprises the heavy and
light chain CDRs or variable regions of BNJ441. In one embodiment,
the antibody comprises the CDR1, CDR2, and CDR3 domains of the VH
region of BNJ441 having the sequence set forth in SEQ ID NO: 12,
and the CDR1, CDR2, and CDR3 domains of the VL region of BNJ441
having the sequence set forth in SEQ ID NO: 8. In another
embodiment, the antibody comprises heavy chain CDR1, CDR2, and CDR3
domains having the sequences set forth in SEQ ID NOs: 19, 18, and
3, respectively, and light chain CDR1, CDR2, and CDR3 domains
having the sequences set forth in SEQ ID NOs: 4, 5, and 6,
respectively. In another embodiment, the antibody comprises VH and
VL regions having the amino acid sequences set forth in SEQ ID NO:
12 and SEQ ID NO: 8, respectively.
[0075] In some embodiment, the antibody comprises the heavy and
light chain CDRs or variable regions of BNJ421. In one embodiment,
the antibody comprises the CDR1, CDR2, and CDR3 domains of the VH
region of BNJ421 having the sequence set forth in SEQ ID NO: 12,
and the CDR1, CDR2, and CDR3 domains of the VL region of BNJ421
having the sequence set forth in SEQ ID NO: 8. In another
embodiment, the antibody comprises heavy chain CDR1, CDR2, and CDR3
domains having the sequences set forth in SEQ ID NOs: 19, 18, and
3, respectively, and light chain CDR1, CDR2, and CDR3 domains
having the sequences set forth in SEQ ID NOs: 4, 5, and 6,
respectively. In another embodiment, the antibody comprises VH and
VL regions having the amino acid sequences set forth in SEQ ID NO:
12 and SEQ ID NO: 8, respectively.
1. Methods of Treating Myasthenia Gravis
[0076] The disclosure provides methods of treating subjects
suffering from myasthenia gravis (MG) by administering an antibody
that specifically binds C5. In other embodiments, the subject is a
mammalian subject.
[0077] As used herein, the term "subject" and "patient" are
interchangeable. In certain embodiments, subjects and/or patients
are mammals. According to certain embodiments, primates include
humans. Thus, in certain embodiments, the subjects or patients
suffering from MG described herein are humans.
[0078] In certain embodiments, MG includes refractory generalized
myasthenia gravis. In some embodiments, refractory generalized
myasthenia gravis is characterized as including subjects or
patients positive for auto-antibodies binding to nicotinic
acetylcholine receptor (anti-AChR) who continue to show marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving current standard of care for myasthenia
gravis such as cholinesterase inhibitor therapy and
immunosuppressant therapy (IST) or who require chronic plasma
exchange or chronic IVIg to maintain clinical stability. In other
embodiments, refractory generalized myasthenia gravis is
characterized as including subjects or patients who continue to
show marked generalized weakness or bulbar signs and symptoms of
myasthenia gravis while receiving current standard of care for
myasthenia gravis such as cholinesterase inhibitor therapy and
immunosuppressant therapy (IST) or who require chronic plasma
exchange or chronic IVIg to maintain clinical stability.
[0079] In other embodiments, MG includes refractory generalized
myasthenia gravis. In some embodiments, refractory generalized
myasthenia gravis is characterized as including subjects or
patients positive for auto-antibodies binding to nicotinic
acetylcholine receptor (anti-AChR) who continue to show marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving cholinesterase inhibitor therapy and
immunosuppressant therapy (IST) and who require chronic plasma
exchange or chronic IVIg to maintain clinical stability. In other
embodiments, refractory generalized myasthenia gravis is
characterized as including subjects or patients who continue to
show marked generalized weakness or bulbar signs and symptoms of
myasthenia gravis while receiving cholinesterase inhibitor therapy
and immunosuppressant therapy (IST) and who require chronic plasma
exchange or chronic IVIg to maintain clinical stability.
[0080] As used herein, the phrase "requires chronic plasma
exchange" to maintain clinical stability refers to the use of
plasma exchange therapy on a patient on a regular basis for the
management of muscle weakness at least every 3 months over the last
12 months.
[0081] As used herein, the phrase "requires chronic IVIg" to
maintain clinical stability refers to the use of IVIg therapy on a
patient on a regular basis for the management of muscle weakness at
least every 3 months over the last 12 months.
[0082] In certain embodiments, treatment of MG includes the
amelioration or improvement of one or more symptoms associated with
MG. Symptoms associated with MG include muscle weakness and
fatigability. Muscles primarily affected by MG include muscles that
control eye and eyelid movement, facial expressions, chewing,
talking, swallowing, breathing, neck movements, and limb
movements.
[0083] In other embodiments, treatment of MG includes the
improvement of a clinical marker for MG progression. These markers
include MG activity of daily living profile (MG-ADL), quantitative
Myasthenia Gravis (QMG) score for disease severity, Myasthenia
Gravis composite (MGC), negative inspiratory force (NIF), forced
vital capacity, MGFA post-intervention status, and other quality of
life measurements. In certain embodiments, MG-ADL is the primary
score for measuring improvement of MG.
[0084] The MG-ADL is an 8-point questionnaire that focuses on
relevant symptoms and functional performance of activities of daily
living (ADL) in MG subjects (see Table 1). The 8 items of the
MG-ADL were derived from symptom-based components of the original
13-item QMG to assess disability secondary to ocular (2 items),
bulbar (3 items), respiratory (1 item), and gross motor or limb (2
items) impairment related to effects from MG. In this functional
status instrument, each response is graded 0 (normal) to 3 (most
severe). The range of total MG-ADL score is 0-24. A clinically
meaningful improvement in a patient's MG-ADL would be a 3 point or
greater reduction in score after 26 weeks of treatment.
[0085] The current QMG scoring system consists of 13 items: ocular
(2 items), facial (1 item), bulbar (2 items), gross motor (6
items), axial (1 item), and respiratory (1 item); each graded 0 to
3, with 3 being the most severe (see Table 2). The range of total
QMG score is 0 -39. The QMG scoring system is considered to be an
objective evaluation of therapy for MG and is based on quantitative
testing of sentinel muscle groups. The MGFA task force has
recommended that the QMG score be used in prospective studies of
therapy for MG. A clinically meaningful improvement in a patient's
QMG would be a 5 point or greater reduction in score after 26 weeks
of treatment.
TABLE-US-00001 TABLE 1 MG ACTIVITY OF DAILY LIVING (MG-ADL) PROFILE
Score Items Grade 0 Grade 1 Grade 2 Grade 3 (0, 1, 2, 3) 1. Talking
Normal Intermittent Constant Difficult to slurring or slurring or
understand nasal speech nasal, but can speech be understood 2.
Chewing Normal Fatigue with Fatigue with Gastric Tube solid food
soft food 3. Swallowing Normal Rare episode of Frequent Gastric
Tube choking choking necessitating changes in diet 4. Breathing
Normal Shortness of Shortness of Ventilator breath with breath at
rest dependence exertion 5. Impairment of None Extra effort, Rest
periods Cannot do one ability to brush but no rest needed of these
teeth or comb hair periods needed functions 6. Impairment of None
Mild, Moderate, Severe, ability to arise sometimes uses always uses
requires from a chair arms arms assistance 7. Double vision None
Occurs, but not Daily, but not Constant daily constant 8. Eyelid
drop None Occurs, but not Daily, but not Constant daily
constant
[0086] The MGC is a validated assessment tool for measuring
clinical status of subjects with MG (16). The MGC assesses 10
important functional areas most frequently affected by MG and the
scales are weighted for clinical significance that incorporates
subject-reported outcomes. See Table 3. MGC will be administered at
Screening, Day 1, Weeks 1-4, 8, 12, 16, 20, and 26 or ET (Visits
1-6, 8, 10, 12, 14, and 17 or ET). A clinically meaningful
improvement in a patient's MGC would be a 3 point or greater
reduction in score after 26 weeks of treatment.
TABLE-US-00002 TABLE 3 MG COMPOSITE SCALE Ptosis, >45 0 11-45
seconds 1 1-10 seconds 2 Immediate 3 upward gaze seconds (PE)
Double >45 0 11-45 seconds 1 1-10 seconds 2 Immediate 4 vision
on seconds lateral gaze, left or right (PE) Eye closure Normal 0
Mild weakness 0 Moderate weakness 1 Severe 2 (PE) (can be forced
(can be forced open weakness open with easily) (unable to effort)
keep eyes closed) Talking (Pt) Normal 0 Intermittent 2 Constant
slurring or 4 Difficult to 6 slurring or nasal but can be
understand nasal speech understood Chewing (Pt) Normal 0 Fatigue
with 2 Fatigue with soft 4 Gastric 6 solid food food tube
Swallowing Normal 0 Rare trouble or 2 Frequent trouble 5 Gastric 6
(Pt) choking (change in diet) tube Breathing Normal 0 SOB with 2
SOB at rest 4 Ventilator 9 exertion Neck Normal 0 Mild 1 Moderate
(~50% 3 Severe 4 Flex/Ext weak .+-.15%) (weakest PE) Shoulder
Normal 0 Mild 2 Moderate (~50% 4 Severe 5 Abd (PE) weak .+-.15%)
Hip flexion Normal 0 Mild 2 Moderate (~50% 4 Severe 5 weak .+-.15%)
0 15 33 50
[0087] The 15-item Myasthenia Gravis Qualify of Life 15 scale
(MG-QOL 15) is a health-related quality of life evaluative
instrument specific to subjects with MG. See Table 4. MG-QOL 15 was
designed to provide information about subjects' perception of
impairment and disability and the degree to which disease
manifestations are tolerated and to be easy to administer and
interpret. The range of total scores is from 0 to 60. Higher scores
translate into a greater extent of a patient's dissatisfaction with
MG related dysfunction. The MG-QOL 15 is completed by the subject.
Higher scores indicate greater extent of and dissatisfaction with
MG-related dysfunction. A clinically meaningful improvement in a
patient's MG-QOL 15 would be a decrease in score after 26 weeks of
treatment.
TABLE-US-00003 TABLE 4 MYASTHENIA GRAVIS QUALIFY OF LIFE 15 SCALE
(MG-QOL 15) Statement: How true in the Not A little Quite Very past
4 weeks? at all bit Somewhat a bit Much Frustrated by condition 0 1
2 3 4 Trouble using my eyes 0 1 2 3 4 Trouble eating 0 1 2 3 4
Condition limits social life 0 1 2 3 4 Condition limits hobbies/fun
0 1 2 3 4 Trouble meeting family's needs 0 1 2 3 4 Need to plan
around condition 0 1 2 3 4 Occupational skills/job 0 1 2 3 4
negatively affected Difficulty speaking 0 1 2 3 4 Trouble driving 0
1 2 3 4 Depressed about condition 0 1 2 3 4 Trouble walking 0 1 2 3
4 Trouble getting around in public 0 1 2 3 4 places Feel
overwhelmed by condition 0 1 2 3 4 Trouble performing personal 0 1
2 3 4 grooming
[0088] The Neuro-QOL Fatigue is a reliable and validated brief
19-item survey of fatigue completed by the subject. Higher scores
indicate greater fatigue and greater impact of MG on activities
(see Table 5). A clinically meaningful improvement in a patient's
Neuro-QQL Fatigue score would be reflected in a decrease in score
after 26 weeks of treatment.
[0089] The EUROQOL (EQ-5D) is a reliable and validated survey of
health status in 5 areas: mobility, self-care, usual activities,
pain/discomfort, and anxiety/depression, completed by the subject.
Each area has 3 levels: level 1 (no problems), level 2 (some
problems), and level 3 (extreme problems) (see FIGS. 2A and 2B).
The EQ VAS records the subject's self-rated health on a vertical,
20 cm visual analogue scale where the endpoints are labeled "Best
imaginable health state, marked as 100" and "Worst imaginable
health state, marked as 0." The EQ-5D is administered at Day 1,
Weeks 4, 8, 12, 16, 20, and 26 or ET (Visits 2, 6, 8, 10, 12, 14,
and 17 or ET). A clinically meaningful improvement in a patient's
EQ-5D would be reflected as an increase in score after 26 weeks of
treatment.
[0090] Subjects with increasingly severe MG can suffer from
potentially fatal respiratory complications including profound
respiratory muscle weakness. Respiratory function is monitored
closely for evidence of respiratory failure in MG subjects and
ventilator support is recommended in the event of consistent
declines in serial measurements of Forced Vital Capacity (FVC) or
Negative Inspiratory Force (NIF), loss of upper airway integrity
(difficulty handling oral secretions, swallowing, or speaking) or
in the setting of emerging respiratory failure. FVC as one of the
test items in QMG is performed when QMG is performed. NIF was
performed using the NIF Meter.
[0091] The MG clinical state is assessed using the MGFA
Post-Intervention Status. Change in status categories of Improved,
Unchanged, Worse, Exacerbation and Died of MG as well as the
Minimal Manifestation (MM) can be assessed.
[0092] According to certain embodiments, patients administered
eculizumab show a reduced MG-ADL. In certain embodiments, the
subjects have an initial MG-ADL score of greater than 6 points. In
other embodiments, the subjects have an initial MG-ADL score
greater than 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,
16, 17, 18, 19, 20, 21, 22, or 23 points. In certain embodiments,
after a course of treatment with eculizumab, the MG-ADL score of
the subject has been reduced to less than 6 points. In other
embodiments, the MG-ADL score has been reduced at least 1 point, at
least 2 points, at least 3 points, at least 4 points, at least 5
points, at least 6 points, at least 7 points, at least 8 points, at
least 9 points, at least 10 points, at least 11 points, at least 12
points, at least 13 points, at least 14 points, at least 15 points,
at least 16 points, at least 17 points, at least 18 points, at
least 19 points, at least 20 points, at least 21 points, at least
22 points, at least 23 points, or at least 24 points after
treatment with eculizumab. In certain embodiments, the MG-ADL score
of the patient is reduced by at least 1 point after a course of
treatment with eculizumab. In other embodiments, the MG-ADL of the
patient is reduced by 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13,
14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 points after a course
of treatment with eculizumab.
[0093] According to certain embodiments, the course of treatment
with eculizumab lasts for 26 weeks. According to other embodiments,
the course of treatment lasts for 26-52, 26-78, 26-104, 26-130,
26-156, 26-182, 26-208 weeks, or more. In other embodiments, the
course of treatment lasts for greater than 26, 27, 28, 29, 30, 31,
32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48,
49, 50, 51, 52, 78, 104, 130, 156, or 182 weeks. According to other
embodiments, the course of treatment lasts for greater than 1, 2,
3, 4, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75,
80, or more years. In certain embodiments, the course of treatment
lasts for the remainder of the subject's life.
[0094] According to certain embodiments, during the course of
treatment, one or more symptoms or scores associated with MG
improves during the course of treatment and is maintained at the
improved level throughout treatment. For example, MG-ADL can
improve after 26 weeks of treatment with a therapeutic antibody
that specifically binds C5 and then remain at the improved level
for the duration of the treatment, which is 52 weeks of treatment
with a therapeutic antibody that specifically binds C5. One example
of a therapeutic antibody that binds C5 is eculizumab.
[0095] In certain embodiments, the first sign of improvement occurs
by 26 weeks of treatment with a therapeutic antibody that
specifically binds C5. According to other embodiments, the first
sign of improvement occurs between weeks 1-26, 26-52, 52-78,
78-104, 104-130, 130-156, 156-182, or 182-208 of treatment with a
therapeutic antibody that specifically binds C5. In other
embodiments, the first sign of improvement occurs at week 1, 2, 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, 52, 78, 104,
130, 156, or 182.
[0096] According to certain embodiments, the first sign of
improvement is maintained for a number of weeks during treatment
with a binding protein that specifically binds C5, such as
eculizumab or an eculizumab variant such as BNJ441. According to
certain embodiments, this number of weeks is at least 26. According
to other embodiments, this number of weeks is 1-26, 26-52, 52-78,
78-104, 104-130, 130-156, 156-182, or 182-208. In other
embodiments, this number of weeks is at least 1, 2, 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, 52, 78, 104, 130, 156, or
182.
[0097] According to certain embodiments, eculizumab or other
anti-C5 antibodies such as BNJ441, BNJ421, 7086, and 8110 can be
administered to a subject suffering from MG at between 600 and 6000
mg. According to other embodiments, the induction dose of
eculizumab or other anti-C5 antibodies such as BNJ441, BNJ421,
7086, and 8110 is between 900 and 1500 mg, 900 and 1200 mg, 900 mg,
or 1200 mg. According to other embodiments, the maintenance dose of
eculizumab or other anti-C5 antibodies such as BNJ441, BNJ 421,
7086, and 8110 is about 600, 700, 800, 900, 1000, 1100, 1200, 1300,
1400, 1500, 1600, 1700, 1800, 1900, 2000, 2500, 3000, 4000, 5000,
or 6000 mg.
[0098] These doses can be administered once a month, once every two
weeks, once a week, twice a week, or daily. According to certain
embodiments, the dose is administered once every two weeks or once
a week. According to other embodiments, eculizumab is administered
to a subject suffering from MG in a multiphase dosing regimen.
According to certain embodiments, the multiphase dosing regimen has
2, 3, 4, 6, 7, 8, 9, 10, or more phases. In certain embodiments,
each phase provides a higher dose than the phase before it.
[0099] In certain embodiments, the eculizumab multiphase dosing
regimen has two phases. The first phase is an induction phase. This
phase provides a dose of 600, 900, 1200, 1500, or 1800 mg per week.
In certain embodiments, this phase lasts for 2, 3, 4, 5, 6, 7, 8,
9, or 10 weeks. In other embodiments, this phase lasts between 2
and 6 weeks. In other embodiments, the phase lasts for 5 weeks.
According to certain embodiments, the dose given any week is higher
than the previous week. In other embodiments, the dose remains the
same for a number of weeks and is then increased. In some
embodiments, the dose remains the same for the first 1, 2, 3, 4, 5,
6, 7, 8, or 9 weeks and is then increased. In other embodiments,
the dose remains the same for the first 4 weeks. According to some
embodiments, the eculizumab dose is administered at between 600 and
1200 mg, 800 and 1500 mg, 900 and 1200 mg, 900 and 1100 mg, 900 and
1000 mg, 800 and 1000 mg, 800 and 1100 mg, or 800 and 1200 mg for a
number of weeks and is then increased. In one embodiment, the
eculizumab dose is administered at about 900 mg on day 1 and is
followed by doses of 900 mg on day 7, 900 mg on day 14, 900 mg on
day 21, and then is increased to 1200 mg for the fifth dose on day
28, and then 1200 mg is administered every 14.+-.2 days
thereafter.
[0100] In one particular embodiment, the eculizumab induction phase
dosing regimen comprises five administered doses on the following
schedule:
[0101] 900 mg on day 1; 900 mg on day 7 (week 1); 900 mg on day 14
(week 2), 900 mg on day 21 (week 3), and 1200 mg on day 28 (week
4), and then 1200 mg is administered every 14.+-.2 days thereafter.
The actual days between each dose may vary during the induction by
1 or 2 days to accommodate unexpected events in the patients'
schedule.
[0102] According to this embodiment, the second phase of eculizumab
dosing is the maintenance phase. The maintenance phase of
eculizumab dosing can last for between 6 weeks and the life of the
subject. According to other embodiments, the maintenance phase
lasts for 26-52, 26-78, 26-104, 26-130, 26-156, 26-182, 26-208
weeks, or more. In other embodiments, the maintenance phase lasts
for greater than 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37,
38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 78,
104, 130, 156, or 182 weeks. According to other embodiments, the
maintenance phase lasts for greater than 1, 2, 3, 4, 5, 10, 15, 20,
25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80 years, or more
years. In certain embodiments, the maintenance phase lasts for the
remainder of the subject's life.
[0103] In certain embodiments, the eculizumab multiphase dosing
regimen includes a third phase. This third phase is used when an MG
patient must undergo a rescue procedure to maintain clinical
stability and includes administering plasma exchange and/or dosing
with IVIg. In this phase after plasma is exchanged a dose of
eculizumab is administered to replace the drug lost in plasma
exchange. According to certain embodiments, this post-rescue
eculizumab dose is between 300 and 1200 mg, 400 and 1500 mg, 500
and 1000 mg, 400 and 800 mg, or 500 and 700 mg. According to
certain embodiments, this post-rescue eculizumab dose is about 600
mg. In another embodiment, in this post-rescue or third phase a 600
mg eculizumab dose is administered within 1 hour after completion
of plasmapheresis. In another embodiment, in the third phase a 600
mg dose is administered within 2 hours after completion of
plasmapheresis. In another embodiment, in the third phase a 600 mg
dose is administered within 3 hours after completion of
plasmapheresis. In another embodiment, in the third phase a 600 mg
dose is administered within 4 hours after completion of
plasmapheresis. In another embodiment, in the third phase a 600 mg
dose is administered within 5 hours after completion of
plasmapheresis. In another embodiment, in the third phase a 600 mg
dose is administered within 6 hours after completion of
plasmapheresis.
2. Pharmaceutical Compositions
[0104] Pharmaceutical compositions comprising eculizumab, either
alone or in combination with prophylactic agents, therapeutic
agents, and/or pharmaceutically acceptable carriers are provided.
The pharmaceutical compositions comprising eculizumab provided
herein are for use in, but not limited to, diagnosing, detecting,
or monitoring a disorder, in preventing, treating, managing, or
ameliorating a disorder or one or more symptoms thereof, and/or in
research. The formulation of pharmaceutical compositions, either
alone or in combination with prophylactic agents, therapeutic
agents, and/or pharmaceutically acceptable carriers, is known to
one skilled in the art.
[0105] An exemplary, non-limiting range for a therapeutically or
prophylactically effective amount of eculizumab or other anti-C5
antibodies such as BNJ441, BNJ 421, 7086, and 8110 provided herein
is 600-5000 mg, for example, 900-2000 mg. It is to be noted that
dosage values may vary with the type and severity of the condition
to be alleviated. It is to be further understood that for any
particular subject, specific dosage regimens may be adjusted over
time according to the individual need and the professional judgment
of the person administering or supervising the administration of
the compositions, and that dosage ranges set forth herein are
exemplary only and are not intended to limit the scope or practice
of the claimed methods.
3. Combination Therapy
[0106] An anti-C5 antibody provided herein also can also be
administered with one or more additional medicaments or therapeutic
agents useful in the treatment of MG. For example, the additional
agent can be a therapeutic agent art-recognized as being useful to
treat myasthenia gravis or condition being treated by the antibody
provided herein. The combination can also include more than one
additional agent, e.g., two or three additional agents.
[0107] The binding agent in various embodiments is administered
with an agent that is a protein, a peptide, a carbohydrate, a drug,
a small molecule, or a genetic material (e.g., DNA or RNA). In
various embodiments, the agent is one or more cholinesterase
inhibitors, one or more corticosteroids, and/or one or more
immunosuppressive drugs (most commonly azathioprine [AZA],
cyclosporin, and/or mycophenolate mofetil [MMF]).
[0108] Without limiting the disclosure, a number of embodiments of
the disclosure are described below for purpose of illustration.
[0109] Item 1: A method of treating refractory generalized
myasthenia gravis in a patient in need thereof comprising
administering a therapeutically effective amount of an
anti-complement component 5 (C5) antibody or antigen binding
fragment thereof to the patient, wherein the patient is
administered the anti-C5 antibody or antigen binding fragment
thereof for at least 26 weeks.
[0110] Item 2: A method of treating refractory generalized
myasthenia gravis in a patient in need thereof comprising
administering a therapeutically effective amount of an anti-C5
antibody or antigen binding fragment thereof to the patient,
wherein the anti-C5 antibody or antigen binding fragment thereof is
eculizumab or an eculizumab variant, and wherein the patient is
administered eculizumab or eculizumab variant for at least 26
weeks.
[0111] Item 3: The method of either items 1 or 2, wherein the
patient is positive for auto-antibodies binding to nicotinic
acetylcholine receptor (anti-AChR) and shows marked generalized
weakness or bulbar signs and symptoms of myasthenia gravis while
receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) and requires chronic plasma exchange or chronic IVIg to
maintain clinical stability, and
[0112] wherein the patient is administered eculizumab for at least
26 weeks.
[0113] Item 4: A method of treating refractory generalized
myasthenia gravis in a patient in need thereof comprising
administering eculizumab to the patient:
[0114] wherein the patient is positive for auto-antibodies binding
to nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) and requires chronic plasma exchange or chronic IVIg to
maintain clinical stability;
[0115] wherein eculizumab is administered using a phased dosing
schedule with an induction phase comprising administering a 900 mg
induction dose of eculizumab on day 1, administering 900 mg doses
of eculizumab on days 7, 14, and 21, and administering 1200 mg of
eculizumab as a fifth induction dose on day 28; and
[0116] wherein the patient is administered eculizumab for at least
26 weeks.
[0117] Item 5: The method of any one of items 1-4, wherein the 28
day induction phase of eculizumab treatment is followed by a
maintenance phase comprising administering 1200 mg of eculizumab 14
days after the fifth induction dose and administering 1200 mg of
eculizumab every 14.+-.2 days thereafter.
[0118] Item 6: The method of any one of items 1-5, wherein the
dosing regimen further comprises a third phase.
[0119] Item 7: The method of any one of items 1-6, wherein the
third phase comprises performing plasmapheresis on the patient and
administering eculizumab at a dose of between 300 mg and 1200 mg to
the patient within 4 hours of completion of plasmapheresis.
[0120] Item 8: The method of any one of items 1-7, wherein the
third phase comprises performing plasmapheresis on the patient and
administering eculizumab at a dose of between 600 mg and 900 mg to
the patient within 90 minutes of completion of plasmapheresis.
[0121] Item 9: The method of any one of items 1-8, wherein the
third phase comprises performing plasmapheresis on the patient and
administering eculizumab at a dose of 600 mg to the patient within
1 hour of completion of plasmapheresis.
[0122] Item 10: The method of any one of items 1-9, wherein the
patient experiences a clinically meaningful improvement (reduction)
in Myasthenia Gravis Activities of Daily Living (MG-ADL) score
after 26 weeks of treatment.
[0123] Item 11: The method of any one of items 1-10, wherein the
clinically meaningful improvement the patient experiences is at
least a 3 point reduction in the patient's MG-ADL score after 26
weeks of treatment.
[0124] Item 12: The method of any one of items 1-11, wherein the
clinically meaningful improvement the patient experiences is at
least a 4 point reduction in the patient's MG-ADL score after 26
weeks of treatment.
[0125] Item 13: The method of any one of items 1-12, wherein the
patient experiences a clinically meaningful improvement (reduction)
in quantitative Myasthenia Gravis score (QMG) after 26 weeks of
treatment.
[0126] Item 14: The method of any one of items 1-13, wherein the
clinically meaningful improvement the patient experiences is at
least a 4 point reduction in the patient's QMG score after 26 weeks
of treatment.
[0127] Item 15: The method of any one of items 1-14, wherein the
clinically meaningful improvement the patient experiences is at
least a 5 point reduction in the patient's QMG score after 26 weeks
of treatment.
[0128] Item 16: The method of any one of items 1-15, wherein the
patient experiences a clinically meaningful improvement (reduction)
in Myasthenia Gravis Composite (MGC) score after 26 weeks of
treatment.
[0129] Item 17: The method of any one of items 1-16, wherein the
clinically meaningful improvement the patient experiences is at
least a 6 point reduction in the patient's MGC score after 26 weeks
of treatment.
[0130] Item 18: The method of any one of items 1-17, wherein the
clinically meaningful improvement the patient experiences is at
least a 10 point reduction in the patient's MGC score after 26
weeks of treatment.
[0131] Item 19: The method of any one of items 1-18, wherein the
patient experiences a clinically meaningful improvement in quality
of life as measured by Myasthenia Gravis Quality of Life
(MG-QOL-15) score after 26 weeks of treatment.
[0132] Item 20: The method of any one of items 1-19, wherein the
clinically meaningful improvement the patient experiences is at
least a 6 point reduction in the patient's MG-QOL-15 score after 26
weeks of treatment.
[0133] Item 21: The method of any one of items 1-20, wherein the
clinically meaningful improvement the patient experiences is at
least an 11 point reduction in the patient's MG-QOL-15 score after
26 weeks of treatment.
[0134] Item 22: The method of any one of items 1-21, wherein the
patient experiences a clinically meaningful improvement (reduction)
in neuro-fatigue as measured by Neuro-QOL Fatigue score after 26
weeks of treatment.
[0135] Items 23: The method of any one of items 1-22, wherein the
clinically meaningful improvement the patient experiences is at
least an 8 point reduction in the patient's Neuro-QOL score after
26 weeks of treatment.
[0136] Item 24: The method of any one of items 1-23, wherein the
clinically meaningful improvement the patient experiences is at
least a 16 point reduction in the patient's Neuro-QOL score after
26 weeks of treatment.
[0137] Item 25: The method of any one of items 1-24, wherein the
patient experiences a clinically meaningful improvement (increase)
in health status as measured by EQ-5D health status score after 26
weeks of treatment.
[0138] Item 26: A method of treating refractory generalized
myasthenia gravis in a patient in need thereof comprising
administering eculizumab to the patient:
[0139] wherein the patient is positive for auto-antibodies binding
to nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) and requires chronic plasma exchange or chronic IVIg to
maintain clinical stability;
[0140] wherein eculizumab is administered using a phased dosing
schedule comprising administering a 900 mg induction dose of
eculizumab on day 1, administering 900 mg doses of eculizumab on
days 7, 14, and 21, and administering 1200 mg as a fifth dose on
day 28; wherein the patient is administered eculizumab for at least
26 weeks;
[0141] wherein the 28 day induction phase of eculizumab treatment
is followed by a maintenance phase comprising administering 1200 mg
of eculizumab 14 days after the fifth induction dose and
administering 1200 mg of eculizumab every 14.+-.2 days thereafter;
and wherein the patient has a clinically meaningful improvement
(reduction) in at least two measurements of generalized myasthenia
gravis severity selected from the group consisting of MG-ADL, QMG,
MGC, MG-QOL, and Neuro-QOL.
[0142] Item 27: A method of treating refractory generalized
myasthenia gravis in a patient in need thereof comprising
administering eculizumab to the patient:
[0143] wherein the patient is positive for auto-antibodies binding
to nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) and requires chronic plasma exchange or chronic IVIg to
maintain clinical stability;
[0144] wherein eculizumab is administered using a phased dosing
schedule comprising administering a 900 mg induction dose of
eculizumab on day 1, administering 900 mg doses of eculizumab on
days 7, 14, and 21, and administering 1200 mg of eculizumab as a
fifth induction dose on day 28;
wherein the patient is administered eculizumab for at least 26
weeks;
[0145] wherein the 28 day induction phase of eculizumab treatment
is followed by a maintenance phase comprising administering 1200 mg
of eculizumab 14 days after the fifth induction dose and
administering 1200 mg of eculizumab every 14.+-.2 days thereafter;
and
[0146] wherein the patient has a clinically meaningful improvement
(reduction) in at least three measurements of generalized
myasthenia gravis severity selected from the group consisting of
MG-ADL, QMG, MGC, MG-QOL, and Neuro-QOL.
[0147] Item 28: The method of any one of items 1-27, wherein the
patient has a clinically meaningful improvement (reduction) in at
least four measurements of generalized myasthenia gravis severity
selected from the group consisting of MG-ADL, QMG, MGC, MG-QOL, and
Neuro-QOL.
[0148] Item 29: The method of any one of items 1-28, wherein the
patient has a clinically meaningful improvement (reduction) in five
measurements of generalized myasthenia gravis severity, wherein the
five measurements of generalized myasthenia gravis severity are
MG-ADL, QMG, MGC, MG-QOL, and Neuro-QOL.
[0149] Item 30: A method of treating refractory generalized
myasthenia gravis in a patient in need thereof comprising
administering eculizumab to the patient:
[0150] wherein the patient is positive for auto-antibodies binding
to nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) and requires chronic plasma exchange or chronic IVIg to
maintain clinical stability;
[0151] wherein eculizumab is administered using a phased dosing
schedule comprising administering a 900 mg induction dose of
eculizumab on day 1, administering 900 mg doses of eculizumab on
days 7, 14, and 21, and administering 1200 mg as a fifth induction
dose on day 28;
[0152] wherein the patient is administered eculizumab for at least
26 weeks; wherein the 28 day induction phase of eculizumab
treatment is followed by a maintenance phase comprising
administering 1200 mg of eculizumab 14 days after the fifth
induction dose and administering 1200 mg of eculizumab every
14.+-.2 days thereafter; and wherein the patient has a clinically
meaningful improvement (reduction) in five measurements of
generalized myasthenia gravis severity, wherein the five
measurements of generalized myasthenia gravis severity are a
reduction in MG-ADL of at least 3 points, a reduction in QMG of at
least 4 points, a reduction in MGC of at least 6 points, a
reduction in MG-QOL of at least 6 points, and a reduction in
Neuro-QOL of at least 8 points.
[0153] Item 31: The method of any one of items 1-30, wherein the
patient has a clinically meaningful improvement (reduction) in five
measurements of generalized myasthenia gravis severity, wherein the
five measurements of generalized myasthenia gravis severity are a
reduction in MG-ADL of at least 4 points, a reduction in QMG of at
least 5 points, a reduction in MGC of at least 10 points, a
reduction in MG-QOL of at least 11 points, and a reduction in
Neuro-QOL of at least 16 points.
[0154] Item 32: The method of any one of items 1-31, wherein
eculizumab is administered by intravenous infusion.
[0155] Item 33: The method of any one of items 1-32, wherein
eculizumab is administered subcutaneously.
[0156] Item 34: The method of any one of items 1-33, wherein the
eculizumab comprises a heavy chain amino acid sequence according to
SEQ ID NO: 10 and a light chain amino acid sequence according to
SEQ ID NO: 11.
[0157] Item 35: The method of any one of items 1-34, wherein the
eculizumab is an eculizumab variant comprising a heavy chain amino
acid sequence according to SEQ ID NO: 14 and a light chain amino
acid sequence according to SEQ ID NO: 11.
[0158] Item 36: The method of any one of items 1-35, wherein the
eculizumab is an eculizumab variant comprising a heavy chain
variable region amino acid sequence according to SEQ ID NO: 12 and
a light chain amino acid sequence according to SEQ ID NO: 11.
[0159] Item 37: The method of any one of items 1-36, wherein the
anti-C5 antibody or antigen binding fragment thereof comprises a
heavy chain variable region amino acid sequence according to SEQ ID
NO: 27 and a light chain variable region amino acid sequence
according to SEQ ID NO: 28.
[0160] Item 38: The method of any one of items 1-37, wherein the
anti-C5 antibody or antigen binding fragment thereof comprises a
heavy chain variable region amino acid sequence according to SEQ ID
NO: 35 and a light chain variable region amino acid sequence
according to SEQ ID NO: 36.
[0161] Item 39: The method of any one of items 1-38, wherein the
patient has failed treatment over one year or more with two or more
ISTs in sequence or in combination.
[0162] Item 40: The method of any one of items 1-39, wherein the
patient has failed at least one IST and requires chronic plasma
exchange or IVIg to control symptoms of myasthenia gravis.
[0163] Item 41: A method of treating refractory generalized
myasthenia gravis in a patient in need thereof comprising
administering eculizumab to the patient:
[0164] wherein the patient is positive for auto-antibodies binding
to nicotinic acetylcholine receptor (anti-AChR) and shows marked
generalized weakness or bulbar signs and symptoms of myasthenia
gravis while receiving therapy for myasthenia gravis including
anticholinesterase inhibitor therapy and immunosuppressant therapy
(IST) and wherein the patient had previously failed treatment with
at least two immunosuppressive agents or failed treatment with at
least one immunosuppressive agent and required chronic plasma
exchange or IVIg, and had an MG-ADL total score .gtoreq.6 at study
entry;
[0165] wherein eculizumab is administered using a phased dosing
schedule with an induction phase comprising administering a 900 mg
induction dose of eculizumab on day 1, administering 900 mg doses
of eculizumab on days 7, 14, and 21, and administering 1200 mg of
eculizumab as a fifth induction dose on day 28;
[0166] wherein the patient is administered eculizumab for at least
26 weeks;
[0167] wherein the 28 day induction phase of eculizumab treatment
is followed by a maintenance phase comprising administering 1200 mg
of eculizumab 14 days after the fifth induction dose and
administering 1200 mg of eculizumab every 14.+-.2 days thereafter;
and
[0168] wherein the patient has a clinically meaningful improvement
(reduction) in at least two measurements of generalized myasthenia
gravis severity selected from the group consisting of MG-ADL, QMG,
and MGC.
[0169] Item 42: The method of any one of items 1-41, wherein the
therapeutically effective amount of eculizumab or eculizumab
variant administered to the patient is maintained at a
concentration of between 50-100 .mu.g/mL in the patient's
serum.
[0170] Item 43: The method of any one of items 1-42, wherein the
patient experiences a discontinuation in the administration of one
or more IST following at least 26 weeks of treatment.
[0171] Item 44: The method of any one of items 1-43, wherein the
patient experiences a reduction in IST dosing following at least 26
weeks of treatment.
[0172] Item 45: The method of any one of items 1-44, wherein the
patient experiences a reduction in one or more IST dosing and a
discontinuation in one or more IST following at least 26 of
treatment.
EXAMPLES
Example 1
Effectiveness of Eculizimab in Treating Myasthenia Gravis in Human
Subjects.
[0173] The primary objective of this trial is to assess the
efficacy of eculizumab as compared with placebo in the treatment of
refractory gMG based on the improvement in the MG-specific
Activities of Daily Living profile (MG-ADL).
[0174] The secondary objectives of this trial include the
following: [0175] Characterize the overall safety and tolerability
of eculizumab as compared with placebo in gMG subjects [0176]
Assess the efficacy of eculizumab as compared with placebo by
additional efficacy measures including: [0177] Quantitative MG
(QMG) Score for Disease Severity [0178] Myasthenia Gravis Composite
(MGC) [0179] Improvement in primary symptoms that are most
clinically meaningful to the subjects [0180] MG-ADL subcategories
for bulbar, respiratory, limb and ocular [0181] Characterize the
effect of eculizumab as compared with placebo on Quality of life
measures [0182] Describe the PK and PD of eculizumab in gMG
subjects.
1. Investigational Plan
1.1. Overall Trial Design and Plan
[0183] Described herein is a randomized, double-blind,
parallel-group, placebo-controlled, multicenter (.about.100 sites
in North America, South America, Europe, Asian Pacific)
approximately two year trial to evaluate the safety and efficacy of
eculizumab for the treatment in subjects with refractory gMG.
Approximately 92 eligible subjects are randomized on Day 1 on a 1:1
ratio to one of two treatment arms (1) eculizumab infusion or (2)
placebo infusion. Subjects may continue to receive stable dose/type
of immunosuppressive therapy (IST), but no new ISTs and no increase
in IST dosage are permitted during the trial. There are 3 periods
in this study: Screening Period, Study Period, and Follow-up Period
(for subjects who withdraw from this trial or who do not enter the
extension trial). See FIG. 1. The overall trial duration for an
individual subject is estimated to take up to 38 weeks including
enrollment and Follow-up. Subjects may be provided the opportunity
to participate in an extension trial (separate protocol) to receive
eculizumab after completion of this trial. A schedule of
assessments for the screening, study and follow-up period is
provided in Table 6.
1.1.1. Screening Period (2-4 Weeks)
[0184] At the screening visit, after obtaining the informed consent
from the subject, the subject is screened for trial eligibility
through medical history review, demographic data, and laboratory
assessments. The medical history review includes confirmation of MG
diagnosis as defined in the inclusion criteria of this protocol,
history of previous treatment/therapies for MG, e.g., thymectomy,
IST including corticosteroids, IVIg and plasma exchange, history of
MG exacerbation or crisis including the duration of each
exacerbation/crisis, the medication taken at the time of each
exacerbation/crisis and the treatment for each
exacerbation/crisis.
[0185] If all inclusion criteria and none of the exclusion criteria
are met, subjects are vaccinated against N. meningitidis, if not
already vaccinated within the time period of active coverage
specified by the vaccine manufacturer or vaccinate according to
current medical/country guidelines. Subjects must be vaccinated at
least 14 days prior to receiving the first dose of study medication
or be vaccinated and receive treatment with appropriate antibiotics
until 14 days after the vaccination. See FIG. 3.
[0186] Use of cholinesterase inhibitor and supportive IST are
allowed during the trial under certain restrictions (see
Concomitant Medications, below). The washout period for IVIg is 4
weeks prior to randomization. The washout period for PE is also 4
weeks prior to randomization. If a subject experiences an MG Crisis
during the Screening Period, the sponsor must be notified.
Following discussion with the sponsor, a decision is made about
whether the subject may continue in the trial, be withdrawn and
possibly, re-screened at a later date.
TABLE-US-00004 TABLE 6 TRIAL DESIGN AND SCHEDULE OF ASSESSMENTS
(STUDY PERIOD) Period/Phase Screening Induction Maintenance Trial
Visit 1 2 3 4 5 6 7 8 9 10 11 Trial Weeks 2-4 Weeks D1 W1 W2 W3 W4
W6 W8 W10 W12 W14 Informed Consent X Medical History X MG History
.sup.1 X MGFA Clinical Classification X Weight X Height X Vital
Signs X X X X X X X X X X X Physical Exam X 12-Lead ECG X
Concomitant Medication X X X X X X X X X X X MG Therapy Status X X
Adverse Event X X X X X X X X X X MG-QOL 15 X X X X X Neuro-QOL
Fatigue X X X X EQ-5D X X X X MG-ADL .sup.2 X X X X X X X X QMG
.sup.3 X X X X X X X X NIF .sup.3 X X X X X X X X MGC .sup.3 X X X
X X X X X MGFA PIS .sup.4 X X C-SSRS X X AChR Ab X X Clinical Lab
Tests .sup.5 X X X X X Pregnancy Test .sup.6 X X PK/PD, Free C5
.sup.7 B/P T/P T/P T/P T/P HAHA .sup.7 B X X Medically Indicated
Tests N. meningitidis Vaccination .sup.8 X Patient Safety
Information Card X X X X X X X X X X Randomization .sup.9 X IP
Infusion .sup.10 X X X X X X X X X X Maintenance Post- Period/Phase
17/ Treatment Trial Visit 12 13 14 15 16 ET* {circumflex over ( )}
Clinical .sup.++ UNS Follow-up Trial Weeks W16 W18 W20 W22 W24 W26
Deterioration Visit +W8 Informed Consent Medical History MG History
.sup.1 MGFA Clinical Classification Weight X Height Vital Signs X X
X X X X X X Physical Exam 12-Lead ECG X Concomitant Medication X X
X X X X X X MG Therapy Status X Adverse Event X X X X X X X X
MG-QOL 15 X X X X Neuro-QOL Fatigue X X X EQ-5D X X X MG-ADL .sup.2
X X X X X QMG .sup.3 X X X X X NIF .sup.3 X X X X X MGC .sup.3 X X
X X X MGFA PIS .sup.4 X X C-SSRS X AChR Ab X X Clinical Lab Tests
.sup.5 X X X X Pregnancy Test .sup.6 X PK/PD, Free C5 .sup.7 T/P
T/P X HAHA .sup.7 X Medically Indicated Tests X N. meningitidis
Vaccination .sup.8 Patient Safety Information Card X X X X X X
Randomization .sup.9 IP Infusion .sup.10 X X X X X X X .sup.10
Abbreviations: AChR Ab = Acetylcholine receptor antibody; B =
Baseline sample; C5 = Complement protein 5; C-SSRS =
Columbia-Suicide Severity Rating Scale; ECG = Electrocardiogram;
ICU = Intensive Care Unit; HAHA = human anti-human antibody; ; IP =
investigational product; MG = Myasthenia Gravis; MGC = MG Composite
Score; MG-ADL = MG Activity of Daily Living (MG-ADL) Profile; MGFA
= Myasthenia Gravis Foundation of America; MGFA PIS = MGFA
Post-Intervention Status; NIF = negative inspiratory force; P =
peak sample; PK/PD = Pharmacokinetics/Pharmacodynamics QMG =
Quantitative MG (QMG) Score for Disease Severity; QOL = Quality of
Life; T = trough sample
1.1.2. Randomization
[0187] All subjects who are vaccinated, and continue to meet the
MG-ADL entry criteria, i.e., MG-ADL total score .gtoreq.6 at
Randomization (Day 1), and have been cleared for randomization by
their respective Principal Investigator (PI), will be randomized on
Day 1 on a 1:1 basis to the Eculizumab Arm or the Placebo Arm. The
randomization stratification is based on the assessment of clinical
classification by the Myasthenia Gravis Foundation of America
(MGFA) (see Table 7) performed at the Screening Visit according to
the following 4 groupings: [0188] a. MGFA Class IIa and IIIc [0189]
b. MGFA Class IVa [0190] c. MGFA Class IIb and IIb, and [0191] d.
MGFA Class IVb
1.1.3. Study Period (26 Weeks)
[0192] Subjects receive IP, either eculizumab or placebo, according
to the randomization and the regimen described in the
Investigational Product and Administration, described below. The
treatment duration for each subject is 26-weeks. Subjects must be
informed of potential signs and symptoms of MG crisis and
instructed to contact the Investigator as soon as possible at onset
of symptom. Every effort is made for the subject reporting Clinical
Deterioration to be evaluated as soon as possible and within 48
hours of notification of the Investigator of the symptom onset. At
the evaluation visit, the Investigator or his/her designee performs
the assessments as specified by this protocol. The Investigator
determines whether or not the subject meets the definition of
Clinical Deterioration as defined by this protocol and treats the
subject accordingly.
TABLE-US-00005 TABLE 7 MGFA CLINICAL CLASSIFICATION Class Clinical
signs I Any ocular muscle weakness. May have weakness of eye
closure. All other muscle strength is normal. II Mild weakness
affecting other than ocular muscles. May also have ocular muscle
weakness of any severity. IIa Predominantly affecting limb or axial
muscles or both. May also have lesser involvement of oropharyngeal
muscles. IIb Predominantly affecting oropharyngeal or respiratory
muscles or both. May also have lesser or equal involvement of limb
or axial muscles or both. III Moderate weakness affecting other
than ocular muscles. May also have ocular muscle weakness of any
severity. IIIa Predominantly affecting limb or axial muscles or
both. May also have lesser involvement of oropharyngeal muscles.
IIIb Predominantly affecting oropharyngeal or respiratory muscles
or both. May also have lesser or equal involvement of limb or axial
muscles or both. IV Severe weakness affecting other than ocular
muscles. May also have ocular muscle weakness of any severity. IVa
Predominantly affecting limb and/or axial muscles. May also have
lesser involvement of oropharyngeal muscles. IVb Predominantly
affecting oropharyngeal or respiratory muscles or both. May also
have lesser or equal involvement of limb or axial muscles or both.
V Defined by intubation, with or without mechanical ventilation,
except when employed during routine postoperative management The
use of a feeding tube without intubation places the patient in
class IVb.
[0193] After completing the 26-week Study Period, subjects may be
provided an opportunity to enter an extension trial (separate
protocol) to receive open-label eculizumab. The visit interval
between this trial and the extension trial is 2 weeks from the last
of IP administration (Visit 17) so there is no interruption in IP
dosing. Subjects entering the extension trial undergo a blinded
eculizumab induction phase similar to the induction in this trial
in order to maintain the blinded treatment assignment of this
trial. If a subject withdraws from this trial at any time after
receiving any amount of IP or does not wish to enter the extension
trial after completion of this trial, the subject is required to
complete the Follow-up Visit for safety measures.
1.1.4. Follow-up Period (8 Weeks Post-Treatment)
[0194] If a subject withdraws or is discontinued from this trial at
any time after receiving any amount of IP or does not wish to enter
the extension trial after completion of this trial, the subject
will be required to complete the Follow-up Visit for safety
measures 8 weeks after the last IP dose administration. If a
subject is discontinued due to an AE, the event will be followed
until it is resolved or in the opinion of the PI is medically
stable.
1.2. Standard Protocol Definitions
[0195] Abbreviations and definitions for the study and follow-up
period are provided in Table 8.
TABLE-US-00006 TABLE 8 LIST OF ABBREVIATIONS AND DEFINITIONS OF
TERMS Abbreviation or Specialist Term Explanation Ab Antibody AChR
Acetylcholine receptor AE Adverse event aHUS Atypical hemolytic
uremic syndrome ANCOVA Analysis of covariance AZA Azathioprine BP
Blood Pressure C5 Complement protein 5 CMAX Maximal concentration
CMIN Minimal concentration eCRF Electronic Case Report Form C-SSRS
Columbia-Suicide Severity Rating Scale ECG Electrocardiogram EDC
Electronic Data Capture EIU Exposure in-utero EOI Event of Interest
EOS End of Study EQ-5D EuroQoL ET Early Termination EU European
Union FAS Full Analysis Set FVC Forced Vital Capacity GCP Good
Clinical Practices gMG Generalized Myasthenia Gravis HAHA Human
Anti-human Antibody HCG human chorionic gonadotropin HR Heart Rate
IB Investigator Brochure ICF Informed Consent Form ICH
International Conference on Harmonization ICU Intensive Care Unit
IEC Independent Ethics Committee IVIg Intravenous Immunoglobulin G
IP Investigational Product IRB Institutional Review Board IST
Immunosuppressant Therapy IV Intravenous IVIg Intravenous
immunoglobulin IXRS Interactive voice or web response system mAb
Monoclonal Antibody MedDRA Medical Dictionary for Regulatory
Activities MG Myasthenia Gravis MG-ADL MG activity of daily living
profile MGC Myasthenia Gravis Composite MGFA Myasthenia Gravis
Foundation of America MM Minimal manifestation MMF Mycophenolate
Mofetil MMT Manual Muscle Test MTX Methotrexate MuSK
Muscle-specific tyrosine kinase NIF Negative inspiratory force NMJ
Neuromuscular junction oMG Ocular Myasthenia Gravis PD
Pharmacodynamics PE Plasmapheresis or Plasma Exchange PI Principal
Investigator PIS Post-Intervention Status PK Pharmacokinetics PNH
Paroxysmal Nocturnal Hemoglobinuria PP Per-Protocol Population QOL
Quality Of Life QMG Quantitative Myasthenia Gravis RR Respiration
Rate RSI Reference Safety Informatoion SAE Serious Adverse Event
SAP Statistical Analysis Plan SFEMG single-fiber electromyography
SOC System Organ Class TEAE Treatment Emergent Adverse Events TESAE
Treatment Emergent SAE US United States VAS Visual Analog Scale
WHODrug World Health Organization Drug Dictionary
1.2.1. Clinical Deterioration
[0196] For this protocol, Clinical Deterioration is defined as
follows: [0197] Subjects who experience an MG Crisis, which is
defined as weakness from MG that is severe enough to necessitate
intubation or to delay extubation following surgery. The
respiratory failure is due to weakness of respiratory muscles.
Severe bulbar (oropharyngeal) muscle weakness often accompanies the
respiratory muscle weakness, or may be the predominant feature in
some subjects; or, [0198] Significant symptomatic worsening to a
score of 3 or a 2-point worsening on any one of the individual
MG-ADL items other than double vision or eyelid droop; or, [0199]
Subjects for whom the treating physician believes that the
subject's health is in jeopardy if rescue therapy is not given
(e.g., emergency situations).
1.2.2. Clinical Evaluation
[0200] The Clinical Evaluators are study staff that have been
trained and certified in administering the MG-ADL, QMG and MGC. The
Clinical Evaluator may be a neurologist, physical therapist or
other study team member delegated by the PI. Clinical Evaluator
training and certification for this protocol will take place either
at the Investigator's meeting or via the sponsor's designated
on-line training portal. 1.2.3.
[0201] Responsibilities for Mg Assessments
[0202] Responsibilities for MG assessments are listed in Table 9.
Throughout the trial, MG assessments should be performed at
approximately the same time of day by a properly trained evaluator,
preferably the same evaluator.
TABLE-US-00007 TABLE 9 MG ASSESSMENTS (RESPONSIBILITIES) Assessment
Evaluator MG-ADL Clinical Evaluator QMG including FVC Clinical
Evaluator NIF Clinical Evaluator MGC Clinical Evaluator MGC (MMT
Components) PI or Neurologist MGFA-PIS PI or Neurologist MGFA
Classification PI or Neurologist Abbreviations: FVC = forced vital
capacity; MG-ADL = Myasthenia Gravis Activity of Daily Living
Profile; MGC = Myasthenia Gravis Composite; MGFA = Myasthenia
Gravis Foundation of America; MGFA-PIS = Myasthenia Gravis
Foundation of America Post Intervention Status; MMT = manual muscle
test; NIF = negative inspiratory force; PI = Principal
Investigator; QMG = Quantitative MG
1.4. Trial Visit Procedures
1.4.1. Screening Visit
[0203] (Days -28 to -14 prior to Baseline [Visit 2/Day 1])
[0204] After obtaining a signed informed consent form, the
following tests and evaluations are performed within 2-4 weeks
prior to randomization at the Baseline Visit (Visit 2/Day 1) to
determine subject eligibility for participation in this trial:
[0205] Review inclusion and exclusion criteria; Register the
subject in the IXRS system to get the subject identification number
in the study and trigger drug shipment if necessary; Record medical
history and demographics; Record MGFA Clinical Classification
[0206] Record MG history: [0207] a. Confirm MG diagnosis as defined
by the protocol inclusion criterion #2 [0208] b. Record the initial
MG clinical presentation (i.e., oMG or gMG). If the initial
clinical presentation was oMG, record the time (date) to onset of
gMG [0209] c. Record the maximum MGFA classification since
diagnosis, if available [0210] d. Record whether the subject ever
required ventilatory support since the diagnosis [0211] e. Record
the number of hospitalizations, including number of ICU stays
(days) and any ventilatory support associated with the
hospitalization within the last 2 years prior to screening [0212] f
Record number and duration of all previous MG exacerbations or
record number and duration of all previous MG exacerbations or
crisis, the medication/therapy taken at the time of each
exacerbation or crisis, and medication/therapy use for treatment of
each exacerbation or crisis, if applicable. [0213] Record MG
Therapy Status (see Table 9) [0214] Measure body weight and height
[0215] Measure vital signs, including assessments of systolic and
diastolic blood pressure (BP), temperature, respiration rate (RR)
and heart rate (HR) [0216] Complete physical examination including
assessments of the following organ/body systems: skin, head, ears,
eyes, nose, throat, neck, lymph nodes, chest, heart, abdomen,
extremities, musculoskeletal, and general neurologic examination.
[0217] Perform a 12-Lead ECG [0218] Record concomitant medications,
including prior IST, IVIg, and/or PE for MG from the time of
diagnosis up to screening and all other concomitant medications
within 30 days prior to the Screening Visit. [0219] Administer
MG-ADL by a properly trained evaluator. The recall period is the
preceding 7 days. [0220] Administer clinical assessments QMG, NIF,
and MGC; these should be performed at approximately the same time
of day by a properly trained evaluator. If the subject is taking a
cholinesterase inhibitor, the dose must be withheld for at least 10
hours prior to the QMG and MGC tests. [0221] Administer MG-QOL15
questionnaire to evaluate quality of life. [0222] Obtain blood
sample for AChR Abs test. [0223] Obtain blood samples for
laboratory tests (chemistry and hematology) (see Table 6) [0224]
Obtain pregnancy test (serum) for all women of childbearing
potential. Note: if the subject is taking/using contraceptive
medication/device, please be sure to record the medication or
device on the appropriate electronic case report form (eCRF) pages
(concomitant medication or procedure). [0225] If all inclusion
criteria and none of the exclusion criteria are met, subjects will
be vaccinated against N. meningitides, if not already vaccinated
within the time period of active coverage specified by the vaccine
manufacturer or according to current medical/country guidelines.
Subjects must be vaccinated at least 14 days prior to receiving the
first dose of study medication or be vaccinated and receive
treatment with appropriate antibiotics until 14 days after the
vaccination. [0226] If a subject experiences an MG Crisis during
the Screening Period, the sponsor should be notified. Following
discussion with the sponsor, a decision will be made about whether
the subject may continue in the trial, be withdrawn and possibly,
re-screened at a later date.
1.4.2. Study Period
[0227] Visit intervals during Induction Phase (Visits 2, 3, 4, 5
and 6) are weekly (every 7.+-.2 days after the last visit). Visit
intervals during the Maintenance Phase (Visits 7-17) are every 2
weeks (every 14 days.+-.2 days since the last visit). Subjects who
fail to return for a scheduled visit must be contacted by the site
study staffs to determine the reason for missing the appointment.
Subjects are strongly encouraged to return to the investigational
site for evaluation if Clinical Deterioration or an AE is suspected
to have occurred. In the exceptional circumstance where a subject
cannot or does not come to the study site for examination, then the
subject will be instructed to see his or her local neurologist or
physician. In this event, the investigational site obtains relevant
medical records as documentation from the local physician's
examination, and enters relevant data in the eCRF as
appropriate.
TABLE-US-00008 TABLE 9 MGFA MG THERAPY STATUS NT No therapy SPT
Status postthymectomy (record type of resection) CH Cholinesterase
inhibitors PR Prednisone IM lmmunosuppression therapy other than
prednisone (define) PE(a) Plasma exchange therapy, acute (for
exacerbations or preoperatively) PE(c) Plasma exchange therapy,
chronic (used on a regular basis) IG(a) IVIg therapy, acute (for
exacerbations or preoperatively) IG(c) IVIg therapy, chronic (used
on a regular basis) OT Other forms of therapy (define)
[0228] As it is vital to obtain information on any subject's
missing visit to assure the missing appointment was not due to a
clinical deterioration or an AE, every effort must be made to
undertake protocol-specified follow-up procedures (see Table 6).
Follow-up due diligence documentation consists of 3 phone calls
followed by 1 registered letter to the subject's last known
address. The study period is summarized in Table 6 and FIG. 6.
1.4.2.1. Induction Phase (Baseline [Visit 2/Day 1] until Visit 6
[Week 4])
1.4.2.1.1. Baseline (Visit 2/Day 1)
[0229] Once all of the eligibility criteria have been confirmed by
the PI, the subject is randomized on Day 1. The following tests and
procedures are completed at the Baseline Visit (Visit 2/Day 1):
[0230] Measure vital signs, including assessments of systolic and
diastolic BP, temperature, RR and HR [0231] Record MG Therapy
Status (see Table 9) [0232] Record any new medications or changes
to concomitant medications [0233] Evaluate and record AEs since the
previous visit [0234] Administer questionnaires to evaluate quality
of life (MG-QOL 15, Neuro-QOL Fatigue, and EuroQoL [EQ-5D]) [0235]
Administer MG-ADL by a properly trained evaluator, preferably the
same evaluator, throughout the trial. The recall period is the
preceding 7 days. If the number of days since the last visit was
<7, the recall period is since the last visit. [0236] Administer
clinical assessments QMG, NIF, and MGC; these should be performed
at approximately the same time of day by a properly trained
evaluator, preferably the same evaluator, throughout the trial. If
the subject is taking a cholinesterase inhibitor, the dose must be
withheld for at least 10 hours prior to the QMG and MGC tests.
[0237] Perform Columbia-Suicide Severity Rating Scale (C-SSRS)
[0238] Obtain blood samples for clinical laboratory tests
(chemistry and hematology) [0239] Obtain pregnancy test (serum) for
all women of childbearing potential. [0240] Collect baseline blood
samples for PK, PD, free C5, and HAHA assays 5-90 minutes before
the infusion of IP. [0241] Instruct the subject on the signs and
symptoms of N. meningitis. Provide the Patient Safety Information
Card describing the IP and emergency contact information to the
subject prior to the first dose of IP. [0242] Randomize the subject
using the IXRS. [0243] Administer the IP infusion over
approximately 35 minutes according to the regimen described in
Section 4.5, and observe subjects for 1 hour after the end of the
IP infusion. [0244] Collect peak blood samples for PK, PD, and free
C5 assays at least 60 minutes after completion of the IP
infusion.
1.4.2.1.2. Visits 3-5 (Weeks 1-3)
[0245] The following tests and procedures are completed: [0246]
Measure vital signs, including assessments of systolic and
diastolic BP, temperature, RR, and HR [0247] Record any new
medications or changes to concomitant medications [0248] Evaluate
and record any new AEs or changes in AEs since the previous visit.
[0249] Administer MG-ADL by a properly trained evaluator,
preferably the same evaluator, throughout the trial. The recall
period is the preceding 7 days. If the number of days since the
last visit was <7, the recall period is since the last visit.
[0250] Administer clinical assessments QMG, NIF, and MGC; these
should be performed at approximately the same time of day by a
properly trained evaluator, preferably the same evaluator,
throughout the trial. If the subject is taking a cholinesterase
inhibitor, the dose must be withheld for at least 10 hours prior to
the QMG and MGC tests. [0251] At Visit 3 (Week 1) only, collect
trough (before IP infusion) blood samples for PK, PD, and free C5
assays. Trough blood samples are to be taken 5-90 minutes before
the IP infusion. [0252] Ensure that the subject has the Patient
Safety Information Card that describes the IP and emergency contact
information. [0253] Obtain study drug kit assignation through the
IXRS. [0254] Administer the IP infusion over approximately 35
minutes according to the regimen described in Section 4.5, and
observe subjects for 1 hour after the end of the IP infusion.
[0255] At Visit 3 (Week 1) only, collect peak (after IP infusion)
blood samples for PK, PD, and free C5 assays. Peak blood samples
are to be taken at least 60 minutes after the completion of the IP
infusion.
1.4.2.1.3. Visit 6 (Week 4)
[0256] The following tests and procedures are completed at this
visit: [0257] Measure vital signs, including assessments of
systolic and diastolic BP, temperature, RR, and HR [0258] Record
any new medications or changes to concomitant medications [0259]
Evaluate and record any new AEs or changes in AEs since the
previous visit [0260] Administer questionnaires to evaluate quality
of life (MG-QOL 15, Neuro-QOL Fatigue, and EQ-5D) [0261] Administer
MG-ADL by a properly trained evaluator, preferably the same
evaluator, throughout the trial. The recall period is the preceding
7 days. If the number of days since the last visit was <7, the
recall period is since the last visit. [0262] Administer clinical
assessments QMG, NIF, and MGC; these should be performed at
approximately the same time of day by an appropriately trained
evaluator, preferably the same evaluator, throughout the trial. If
the subject is taking a cholinesterase inhibitor, the dose must be
withheld for at least 10 hours prior to the QMG and MGC tests.
[0263] Assess change from baseline in the MGFA Post-Intervention
Status (see Table 10). [0264] Collect blood samples for clinical
laboratory tests (chemistry and hematology). [0265] Collect trough
blood samples for PK, PD, free C5, and HAHA assays 5-90 minutes
before the infusion of IP. [0266] Ensure that the subject has the
Patient Safety Information Card that describes the IP and emergency
contact information. [0267] Obtain study drug kit assignation
through the IXRS. [0268] Administer the IP infusion over
approximately 35 minutes according to the regimen described in
Section 4.5, and observe subjects for 1 hour after the end of the
IP infusion. [0269] Collect peak blood samples for PK, PD, and free
C5 assays at least 60 minutes after completion of the IP infusion.
1.4.2.2. Maintenance Phase (Visit 7 [Week 6] until End of Study
Period Visit 17 [Week 26] or Early Termination of Visit)
[0270] During the Maintenance Phase, subjects return for infusions
of IP every 2 weeks (14.+-.2 days), according to the regimen
described in Section 4.5. The following tests and procedures are
completed at every visit beginning at Visit 7 (Week 6) and
continuing until the End of Study (EOS), Visit 17 (Week 26) or at
Early Termination (ET): [0271] Measure vital signs, including
assessments of systolic and diastolic BP, temperature, RR, and HR
[0272] Record any new medications or changes to concomitant
medications [0273] Evaluate and record any new AEs or changes in
AEs since the previous visit. [0274] Ensure that the subject has
the Patient Safety Information Card that describes the IP and
emergency contact information. [0275] Administer the IP and observe
subjects for 1 hour after the end of the IP infusion.
[0276] IP will be administered after completion of other tests and
procedures, excluding the peak blood sampling for PK/PD and free C5
assay.
[0277] At Visit 8 (Week 8), Visit 10 (Week 12), Visit 12 (Week 16),
Visit 14 (Week 20), and until the EOS, Visit 17 (Week 26) or at ET,
the following procedures are also completed, in addition to the 5
preceding procedures listed for the maintenance phase: [0278]
Administer questionnaires to evaluate quality of life (MG-QOL 15,
Neuro-QOL Fatigue, and EQ-5D) [0279] Administer MG-ADL by a
properly trained evaluator, preferable the same evaluator,
throughout the trial. The recall period is the preceding 7 days.
[0280] Administer clinical assessments QMG, NIF, and MGC; these
should be performed at approximately the same time of day by a
properly trained evaluator, preferably the same evaluator,
throughout the trial. If the subject is taking a cholinesterase
inhibitor, the dose must be withheld for at least 10 hours prior to
the QMG and MGC tests. [0281] Perform C-SSRS only at Visit 10 (Week
12) and Visit 17 (Week 26)/ET. The blood sample for the HAHA assay
is to be collected 5-90 minutes before the infusion of IP. [0282]
Obtain blood sample for clinical laboratory tests (chemistry and
hematology). [0283] Obtain blood sample for the AChR Abs test and
HAHA assay only at Visit 10 (Week 12) and Visit 17 (Week 26)/ET.
[0284] Collect trough blood samples for PK, PD, and free C5 assays
5-90 minutes before the infusion of IP only at Visits 8, 10, 14 and
17/ET (Weeks 8, 12, 20, and 26). [0285] Collect peak blood samples
for PK, PD, and free C5 assays at least 60 minutes after completion
of the IP infusion only at Visits 8, 10, 14 and 17/ET (Weeks 8, 12,
20, and 26). [0286] Measure body weight only at Visit 17 (Week
26)/ET. [0287] Perform a 12-Lead ECG only at Visit 17 (Week 26)/ET.
[0288] Record MG Therapy Status (see Table 9) only at Visit 17
(Week 26)/ET. [0289] Obtain pregnancy test must for all women of
childbearing potential at Visit 17 (Week 26)/ET. [0290] Assess
change from baseline in the MGFA Post-Intervention Status only at
Visit 10 (Week 12) and Visit 17 (Week 26)/ET.
1.4.2.3. Visits for MG Crisis or Clinical Deterioration
[0291] The evaluation visit for an MG crisis or Clinical
Deterioration must be performed as soon as possible, within 48
hours of notification of the Investigator of the symptom onset.
Additional evaluation visits can be scheduled at the discretion of
the investigator. The following tests and procedures are completed
at this visit: [0292] Measure vital signs, including assessments of
systolic and diastolic BP, temperature, RR, and HR [0293] Record
any new medications or changes to concomitant medications,
including all treatments for MG [0294] Evaluate and record any new
AEs or changes in AEs since the previous visit [0295] Administer
MG-ADL by a properly trained evaluator, preferably the same
evaluator, throughout the trial. The recall period is the preceding
7 days or since the last visit whichever occurs earlier. [0296]
Administer clinical assessments QMG, NIF, and MGC; these should be
performed at approximately the same time of day by a properly
trained evaluator, preferably the same evaluator, throughout the
trial. [0297] Collect blood sample for the AChR Abs test [0298]
Collect blood samples for clinical laboratory tests (chemistry and
hematology) [0299] If medically indicated for evaluation of
Clinical Deterioration, additional tests may be performed at the
discretion of the Investigator. [0300] PK, PD sampling at or during
crisis or deterioration Visit: [0301] Collect one blood sample for
PK, PD, and free C5 assays if no IP is administered. [0302] If IP
is administered at the MG Crisis evaluation visit or at the visit
for Clinical Deterioration, according to the protocol schedule,
collect two blood samples, trough and peak, at [1] 5-90 minutes
before the IP infusion and [2] at least 60 minutes after completion
of the IP infusion. [0303] If the subject receives PE at the time
of a crisis or Clinical Deterioration, a supplemental dose of IP
will be administered. Collect three blood samples for PK, PD, and
free C5 at [1] 5-90 minutes before PE, [2] 60 minutes after PE and
before IP infusion, and [3] at least 60 minutes after completion of
the IP infusion. [0304] IP administration: [0305] Subject will
continue IP administration in accordance with protocol specified IP
administration schedule. [0306] If the crisis or Clinical
Deterioration Visit coincides with a regular visit per protocol,
subject will receive the regular scheduled IP administration per
protocol schedule. [0307] If subjects undergo PE, a supplemental
dose (2 vials IP) must be administered within 60 minutes after each
PE session. If the subject is scheduled to receive the
protocol-scheduled dose on the day of a PE session, then the
scheduled dose should be administered within 60 minutes after the
end of the PE.
1.4.2.4 Unscheduled Visit
[0308] Additional (Unscheduled) visits outside the specified visits
are permitted at the discretion of the Investigator. Procedures,
tests, and assessments are performed at the discretion of the
Investigator. If an Unscheduled Visit is performed, any tests,
procedures, or assessments performed at the Unscheduled Visits must
be recorded on the eCRFs.
1.4.3. Safety Follow-Up Period (Post-Treatment +Week 4) Safety
Follow-Up Period (Post-Treatment +Week 8)
[0309] If a subject withdraws from the trial at any time during the
Study Period after receiving any amount of IP (eculizumab or
placebo) or does not wish to enter the extension trial after
completion of this trial, a follow up visit for safety assessment
is required at 4 weeks after the last dose of IP. The following
tests and procedures will be completed at the safety follow-up
visit: [0310] Measure vital signs, including assessments of
systolic and diastolic BP, temperature, RR, and HR [0311] Record
any new medications or changes to concomitant medications [0312]
Evaluate and record any new AEs or changes in AEs since the
previous visit. [0313] Administer MG-QOL15 [0314] Administer MG-ADL
by a properly trained evaluator, preferably the same evaluator,
throughout the trial. The recall period is the preceding 7 days.
[0315] Administer clinical assessments QMG, NIF, and MGC; these
should be performed at approximately the same time of day by a
properly trained evaluator, preferably the same evaluator,
throughout the trial. If the subject is taking a cholinesterase
inhibitor, the dose must be withheld for at least 10 hours prior to
the QMG and MGC tests. [0316] Assess change from baseline in MGFA
Post-Intervention Status (see Table 10).
TABLE-US-00009 [0316] TABLE 10 MGFA POST-INTERVENTION STATUS
Complete stable remission The patient has had no symptoms or signs
of MG for at least (CSR) 1 year and has received no therapy for MG
during that time. There is no weakness of any muscle on careful
examination by someone skilled in the evaluation of neuro- muscular
disease. Isolated weakness of eyelid closure is accepted.
Pharmacological remission The same criteria as for CSR, except that
the patient continues (PR) to take some form of therapy for MG.
Patients taking cholinesterase inhibitors are excluded from this
category because their use suggests the presence of weakness.
Minimal manifestations The patient has no symptoms of functional
limitations from (MM) MG, but has some weakness on examination of
some muscles. This class recognizes that some patients who
otherwise meet the definition of CSR or PR do have weak- ness that
is only detectable by careful examination. MM-0 The patient has
received no MG treatment for at least 1 year. MM-1 The patient
continues to receive some form of immuno- suppression, but no
cholinesterase inhibitors or other symptomatic therapy. MM-2 The
patient has received on low-dose cholinesterase inhibitors (<120
mg pyridostigmine/day) for at least 1 year. MM-3 The patient has
received cholinesterase inhibitors or other symptomatic therapy and
some form of immuno- suppression during the past year. Change in
Status Improved (I) A substantial decrease in pretreatment clinical
manifestations or a sustained substantial reduction in MG
medications as defined in the protocol. In prospective studies,
this should be defined as a specific decrease in QMG score.
Unchanged (U) No substantial change in pretreatment clinical
manifestations or reduction in MG medications as defined in the
protocol. In prospective studies, this should be defined in terms
of a maximum change in QMG score. Worse (W) A substantial increase
in pretreatment clinical manifestations or a substantial increase
in MG medications as defined in the protocol. In prospective
studies, this should be defined as a specific increase in QMG
score. Exacerbation (E) Patients who have fulfilled criteria of
CSR, PR, or MM, but subsequently developed clinical findings
greater than permitted by these criteria. Died of MG (D of MG)
Patients who died of MG, of complications of MG therapy, or within
30 days after thymectomy. List the cause (see Morbidity and
Mortality data).
[0317] If a subject is discontinued due to an AE, the AE will be
followed until it is resolved or, in the opinion of the PI, is
determined medically stable.
1.5. Number of Subjects
[0318] Approximately 92 subjects with refractory gMG are randomized
in a 1:1 (eculizumab: placebo) ratio at approximately 100 centers.
Randomization is across centers and is stratified based on MGFA
clinical classifications (Class a vs. Class b and Classes II and
III vs. Class IV) (see Table 7).
1.6. Treatment Assignment
[0319] Approximately 92 subjects with refractory gMG are
randomized, 46 subjects to eculizumab and 46 subjects to placebo.
All patients will remain on assigned double-blind treatment until
the EOS/ET visit. Randomized subjects who discontinue after
initiation of study treatment are not being replaced. Assignment
will be performed through the IXRS at each visit.
2. Selection and Withdrawal of Subjects
2.1. Subject Inclusion Criteria
[0320] 1. Male or female subjects .gtoreq.18 years old [0321] 2.
Diagnosis of MG must be made by the following tests: [0322]
Positive serologic test for anti-AChR Abs as confirmed at
screening, and [0323] One of the following: [0324] a. History of
abnormal neuromuscular transmission test demonstrated by
single-fiber electromyography (SFEMG) or repetitive nerve
stimulation, or [0325] b. History of positive anticholinesterase
test, e.g., edrophonium chloride test, or c. Subject has
demonstrated improvement in MG signs on oral cholinesterase [0326]
inhibitors, as assessed by the treating physician. [0327] 3. MGFA
Clinical Classification Class II to IV at screening. [0328] 4.
MG-ADL total score must be .gtoreq.6 at screening and Randomization
(Day 1) [0329] 5. Subjects who have [0330] a. Failed treatment over
one year or more with 2 or more ISTs* (either in combination or as
mono-therapy), i.e., continue to have impairment ADLs (persistent
weakness, experience crisis, or unable to tolerate IST) despite
ISTs. Or, [0331] b. Failed at least one IST and require chronic
plasma exchange or IVIg to control symptoms, i.e., subjects who
require PE or IVIg on a regular basis for the management of muscle
weakness at least every 3 months over last 12 months. [0332]
*Immunosuppressant's include, but are not limited to,
corticosteroids AZA, [0333] MMF, methotrexate (MTX), cyclosporine,
tacrolimus, or cyclophosphamide. [0334] 6. If subjects who enter
the study are receiving AZA they must have been on AZA for
.gtoreq.6 months and have been on a stable dose for .gtoreq.2
months prior to screening. [0335] 7. If subjects who enter the
study are receiving other ISTs, i.e., MMF, MTX, cyclosporine,
tacrolimus, or cyclophosphamide, they must have been on the IST for
.gtoreq.3 months and have been on a stable dose for .gtoreq.1 month
prior to screening. [0336] 8. If subjects who enter the study are
receiving oral corticosteroids, they must have been on a stable
dose for .gtoreq.4 weeks (28 days) prior to screening. [0337] 9. If
subjects who enter the study are receiving a cholinesterase
inhibitor they must have been on a stable dose for .gtoreq.2 weeks
prior to screening. [0338] 10. Female subjects of child-bearing
potential must have a negative pregnancy test (serum human
chorionic gonadotropin [HCG]). All subjects must practice an
effective, reliable and medically approved contraceptive regimen
during the study and for up to 5 months following discontinuation
of treatment. [0339] 11. Subject must give written informed
consent. [0340] 12. Subject must be able and willing to comply with
study procedures.
2.2. Subject Exclusion Criteria
[0340] [0341] 1. History of thymoma or other neoplasms of thymus.
[0342] 2. History of thymectomy within 12 months prior to
screening. [0343] 3. Weakness only affecting ocular or pen-ocular
muscles (MGFA Class I). [0344] 4. MG crisis at screening (MGFA
Class V) [0345] 5. Pregnancy or lactation. [0346] 6. Any systemic
bacterial or other infection, which is clinically significant in
the opinion of the Investigator and has not been treated with
appropriate antibiotics [0347] 7. Unresolved meningococcal
infection. [0348] 8. Use of IVIg within 4 weeks prior to
Randomization (Day 1). [0349] 9. Use of PE within 4 weeks prior to
Randomization (Day 1). [0350] 10. Use of rituximab within 6 months
prior to screening. [0351] 11. Participation in any other
investigational drug trial or exposure to other investigational
agent, device, or procedures within 30 days prior to screening.
[0352] 12. Subjects who have received previous treatment with
eculizumab. [0353] 13. Hypersensitivity to murine proteins or to
one of the excipients of eculizumab. [0354] 14. Any medical
condition that, in the opinion of the Investigator, might interfere
with the subject's participation in the study, poses any added risk
for the subject, or confounds the assessment of the subjects.
2.3. Subject Withdrawal Criteria
[0355] 2.3.1. Withdrawal of Subjects from the Trial
[0356] Subjects are allowed to withdraw consent at any time. Every
effort should be made to ensure subjects are willing to comply with
trial participation prior to conducting the screening procedures
and the subjects should be fully informed of the restrictions
related to the change of concomitant medications during the trial.
Investigators may choose to discontinue a subject's treatment
because of AEs, as well as conditions or illnesses that preclude
compliance with the protocol from the standpoint of the subject's
safety or well-being. The study staff should notify the Sponsor and
their site monitor of all trial withdrawals as soon as
possible.
[0357] Reproduction and development studies with eculizumab have
not been performed; therefore, eculizumab should not be
administered to pregnant women. At the time of the last follow-up
visit, all subjects of childbearing potential must continue to use
adequate contraception for up to 5 months following discontinuation
of eculizumab treatment. If a subject becomes pregnant, the IP must
be immediately discontinued and the Sponsor must be notified. Each
pregnancy will be followed to term and the Sponsor notified
regarding the outcome.
2.3.2. Handling of Withdrawals
[0358] When a subject withdraws or is withdrawn from the trial, the
Investigator shall record the withdrawal reason(s). Whenever
possible, all subjects who prematurely withdraw from the trial will
undergo all assessments at the ET visit for safety as per the
Schedule of Assessments (Table 6). A follow-up visit for safety
assessment is required at 8 weeks after the last dose of IP
administration (Table 6).
[0359] If a subject is discontinued due to an AE, the event will be
followed until it is resolved or in the opinion of the PI the
subject is determined to be medically stable. Every effort will be
made to undertake protocol-specified safety follow-up
procedures.
[0360] Subjects who fail to return for final assessments will be
contacted by the site study staffs in an attempt to have them
comply with the protocol. As it is vital to obtain follow-up data
on any subject withdrawn because of an AE or SAE, follow-up due
diligence documentation will consist of 3 phone calls followed by 1
registered letter to the subject's last known address. In any case,
every effort must be made to undertake protocol-specified safety
follow-up procedures.
2.3.3. Sponsor's Termination of Trial
[0361] Alexion Pharmaceuticals, Inc. or a regulatory authority may
discontinue the trial at any time for any reason including, for
example, clinical or administrative reasons.
2.3.4. End of Trial Definition
[0362] The end of trial is defined as the last visit completed by
the last patient.
3. Treatment of Subjects
3.1. Description of Investigational Product
[0363] Eculizumab (600 mg, 900 mg or 1200 mg) or matching placebo
is administered intravenously over approximately 35 minutes
according to the regimen shown in Table 11.
TABLE-US-00010 TABLE 11 TRIAL DOSE REGIMEN Frequency Equivalent of
Investigational # of Eculizumab Dose Period Product Administration
Visits Vials Dose Induction Weekly (every 7 .+-. 2 days) 2-5 3 900
mg Phase 6 4 1200 mg Maintenance Every 2 weeks (14 .+-. 2 days)
7-17 4 1200 mg Phase from the fifth dose onward Supplement If PE is
given due to a 2 600 mg Doses* Clinical Deterioration, administer
within 60 minutes after the end of each PE session as described
below*.
[0364] Induction Phase
[0365] Eculizumab or placebo: 3 vials of IP (equivalent to 900 mg
of eculizumab) weekly for 4 weeks (every 7 days.+-.2 days) followed
by 4 vials of IP (equivalent to 1200 mg of eculizumab) one week
later for the fifth dose (Visit 6/Week 4).
[0366] Maintenance Phase
[0367] Eculizumab or placebo: 4 vials of IP (equivalent to 1200 mg
of eculizumab) every 2 weeks (14 days.+-.2 days)
[0368] *Supplemental Doses
[0369] If PE is administered due to a Clinical Deterioration (as
defined by this protocol), supplemental IP (2 vials, equivalent to
600 mg of eculizumab or matching placebo) will be administered
within 60 minutes after the end of each PE session. If PE is
administered on a day of regularly scheduled IP administration,
subjects will receive the regularly scheduled number of vials (3
vials on Visits 2-4; 4 vials on all other visits) within 60 minutes
after each PE session.
3.2. Concomitant Medications
3.2.1. Allowed Medications
3.2.1.1. Palliative and Supportive Care
[0370] Palliative and supportive care is permitted during the
course of the trial for underlying conditions.
[0371] The following medications are allowed under certain
circumstances and restrictions.
3.2.1.2. Cholinesterase Inhibitors
[0372] For subjects who enter the trial receiving a cholinesterase
inhibitor for at least two weeks prior to screening, the dose and
schedule of their cholinesterase inhibitor is maintained stable
throughout the entire Study Period, unless there is compelling
medical need. Increases in cholinesterase therapy that are required
as a result of inter-current illness or other medical cause of
deterioration are permitted but dosing should be returned to dosing
levels at trial entry as soon as feasible and the trial sponsor
should be notified of the change. [0373] Cholinesterase inhibitor
treatment must be withheld for at least 10 hours prior to QMG and
MGC tests. [0374] If a decrease in cholinesterase inhibitor is
considered based on clinical evaluation, sponsor approval must be
obtained prior to the change in dose in order for the subject to
remain on study. Dose increase as a result of inter-current illness
or other medical cause is permitted, but dose should be returned to
dose level at trial entry as soon as feasible and the trial sponsor
should be notified.
3.2.1.3. Immunosuppressive Agents
[0375] The following immunosuppressive agents are allowed during
the trial: corticosteroid, AZA, MMF, MTX, tacrolimus, cyclosporine,
or cyclophosphamide. The immunosuppressive agent(s) and its
appropriate dose level to be used for an individual subject is at
the discretion of the treating physician. [0376]
Corticosteroid--for subjects who enter the trial receiving oral
corticosteroid, e.g., prednisone, the dose/schedule must have been
stable for four weeks prior to trial and may not be changed during
the entire double-blind Study Period. If a decrease or taper in
steroid dose is considered during the Study Period based on
clinical evaluation, sponsor approval must be obtained prior to the
change in order for the subject to remain on trial. If the dose
level subsequently must be increased, the dose level increase
cannot be above the dose level reported at the baseline (at the
start of randomized treatment). [0377] High-dose steroid should be
reserved for subjects that experience Clinical Deterioration as
defined by this protocol. Every effort should be made to notify the
Sponsor within 24 hours of administration should a subject require
a rescue therapy for Clinical Deterioration. [0378] AZA, MMF, MTX,
tacrolimus, cyclosporine or cyclophosphamide--for subjects who
enter the trial receiving above mentioned immunosuppressive agents,
the dose regimen of the immunosuppressive agent may not be changed
during the entire double-blind Study Period. If a change in the
dose regimen is considered due to known toxicity or side effects
associated with the given immunosuppressive agent, sponsor approval
must be obtained prior to the dose change in order for the subject
to remain on the trial. A different immunosuppressive agent cannot
be added or substituted during the 26-week double-blind Study
Period.
3.2.1.4. Plasma Exchange/Plasmapheresis (PE)/IVIg
[0379] Use of PE or IVIg will be allowed for subjects who
experience a Clinical Deterioration as defined by this protocol.
The rescue therapy used for a particular subject is at the
discretion of the treating physician. Every effort should be made
to notify the Sponsor within 24 hours should a subject require a
rescue therapy.
[0380] If PE is administered as a rescue therapy, supplemental IP
(2 vials) are administered within 60 minutes after the end of each
PE session. Routine (per protocol schedule) IP administration is
continued per the specified dose-administration schedule for the
subject. If the subject is scheduled to receive the
protocol-scheduled dose on the day of a PE session, then the
scheduled dose is administered within 60 minutes after the end of
the PE session.
3.2.2. Disallowed Medications
[0381] The following concurrent medications are prohibited during
the trial: [0382] Use of rituximab
3.3. Treatment Compliance
[0383] The infusion of IP into subjects is under the supervision of
the PI/Sub-Investigator or their designee, to ensure that the
subject receives the appropriate dose at the appropriate
time-points during the trial.
[0384] Subjects who fail to return for a scheduled visit within the
accepted intervals must be contacted by the site study staffs to
determine the reason for missing the appointment. Instructions for
handling of missing visits are provided in Section 1.4.2.
3.4. Randomization and Blinding
3.4.1. Randomization
[0385] Subjects are randomized on Day 1 after the Investigator has
verified that they are eligible. Subjects are randomized in a 1:1
ratio of eculizumab infusion to placebo infusion. The randomization
will be across centers using an IXRS. The randomization
stratification will be based on MGFA clinical classification
assessed at the Screening Visit according to the following 4
groupings:
[0386] a. MGFA Class IIa and IIIa
[0387] b. MGFA Class IVa
[0388] c. MGFA Class IIb and IIIb, and
[0389] d. MGFA Class IVb
The MGFA clinical classifications are described in Table 7.
3.4.2. Blinding and Unblinding
[0390] All trial subjects, investigational site personnel, sponsor
staff, sponsor designees, and all staff directly associated with
the conduct of the trial are blinded to the subject treatment
assignments. The double blind is maintained by using identical IP
kits and labels for eculizumab and placebo. The placebo has an
identical appearance to that of eculizumab. The random code is
maintained by Almac Clinical Services. There is no antidote to
reverse the effects of eculizumab.
[0391] Therefore, unblinding would not be helpful in the planning
of patient treatment for a given event. Unblinding should only be
considered for the safety of the subject. If unblinding is deemed
necessary by the Investigator, the Investigator can unblind the
patient's treatment allocation using IXRS. The Investigator must
note the date, time and reason for unblinding.
[0392] The Investigator should inform the Medical Monitor that the
patient was unblinded, however they are not required to reveal to
the Medical Monitor the patients' treatment allocation.
[0393] When an AE is an unexpected related serious AE, the blind
will be broken by the Sponsor only for that specific subject. The
blind will be maintained for persons responsible for the ongoing
conduct of the study (such as the management, monitors,
investigators, etc.) and those responsible for data analysis and
interpretation of results at the conclusion of the study, such as
biometrics personnel. Unblinded information will only be accessible
to those who need to be involved in the safety reporting to Health
Authorities, Ethics Committees and/or IRBs.
[0394] Investigators will receive only blinded information unless
unblinded information is judged necessary for safety reasons.
4. Investigational Product Materials and Management
4.1. Investigational Product
[0395] Each vial of IP contains eculizumab 300 mg or matching
placebo for IV administration.
4.2. Investigational Product Packaging and Labeling
[0396] The active IP, eculizumab is manufactured and supplied by
Alexion in single 30 mL vials as a solution concentration of 10
mg/ml. The comparator product is manufactured by Alexion
Pharmaceuticals, Inc., as a matching sterile, clear, colorless
solution with the same buffer components but without active
ingredient, in an identical 30 ml vial. See Table 12.
[0397] All study medication is prepared in vials, packaged in kits,
labeled in an identical manner.
[0398] IP vials will be individually packaged into a kit. Both
vials and kits will be labeled according to the protocol and local
regulatory requirements. Each kit will have a label describing the
contents and a place for the pharmacist to record the subject
number and initials.
[0399] Study medication is shipped and released to each
participating trial center upon receipt of all required essential
documents based upon federal, state, and local regulations (Table
12).
TABLE-US-00011 TABLE 12 INVESTIGATIONAL PRODUCT Investigational
Product Name: Eculizumab Placebo Dosage Form: Concentrate for
Solution for solution for infusion infusion Unit Dose: 300 mg 0 mg
Route of Administration: Intravenous Infusion Intravenous Infusion
Physical Description: 30 mL vial 30 mL vial Manufacturer: Alexion
Alexion Pharmaceuticals, Pharmaceuticals, Inc. Inc.
4.3. Investigational Product Storage
[0400] IP is released to the site upon receipt of all required
essential documents based upon federal, state, and local
regulations. See Table 12.
[0401] Upon arrival at the center, the IP is promptly removed from
the shipping cooler and stored in refrigerated conditions at 2 to
8.degree. C. The pharmacist should immediately record the reception
of the IP and notify the distributor if vials are damaged and/or if
temperature excursions have occurred during transportation. IP must
be stored in a secure, limited-access storage area and temperature
must be monitored daily.
[0402] Diluted solutions of IP may be stored at 2 to 8.degree. C.
(36-46.degree. F.) for up to 24 hours prior to administration. If
the IP is prepared more than 4 hours in advance of a subject's
visit, the diluted material should be stored at 2 to 8.degree. C.
The solution should be allowed to warm to room temperature prior to
administration. The material must not be heated (e.g., by using a
microwave or other heat source) other than by ambient air
temperature.
4.4. Investigational Product Preparation
[0403] Infusions of IP are prepared using aseptic technique. Each
vial of IP contains 300 mg of active ingredient in 30 mL of product
solution or matching placebo.
[0404] Withdraw the required amount of IP from the vials. Transfer
the recommended dose to an infusion bag. Dilute the IP to a final
concentration of 5 mg/mL by addition to the infusion bag of the
appropriate amount (equal volume) of 0.9% Sodium Chloride
Injection, USP; 0.45% Sodium Chloride Injection, USP; 5% Dextrose
in Water Injection, USP; or Ringer's Injection, USP. The final
volume of a 5 mg/mL diluted IP solution is 120 mL for 600 mg doses
(2 vials), 180 mL for 900 mg doses (3 vials) and 240 mL for 1200 mg
doses (4 vials) as shown in Table 13.
TABLE-US-00012 TABLE 13 INVESTIGATIONAL PRODUCT RECONSTITUTION
Investigational Volume Volume of Total Volume of Product of IP
Diluent .sup.a Administration 600 mg (2 vials) 60 mL 60 mL 120 900
mg (3 vials) 90 mL 90 mL 180 1200 mg (4 vials) 120 mL 120 mL 240
.sup.a Choose one of the following diluents: a. 0.9% sodium
chloride; b. 0.45% sodium chloride; c. 5% dextrose in water; d.
Ringer's injection
[0405] Gently invert the infusion bag containing the diluted IP
solution to ensure thorough mixing of the product and diluents.
Discard any unused portion left in a vial, as the product contains
no preservatives. The diluted solution should be allowed to warm to
room temperature by exposure to ambient air prior to
administration.
4.5. Administration
[0406] Do not Administer as an Iv Push or Bolus Injection IP is
only administered via IV infusion and must be diluted to a final
concentration of 5 mg/mL prior to administration. Prior to
administration, if the diluted solution is refrigerated, it is
allowed to warm to room temperature by exposure to ambient air. The
diluted solution must not be heated in a microwave or with any heat
source other than ambient air temperature. Parenteral drug products
are inspected visually for particulate matter and discoloration
prior to administration.
[0407] The diluted IP is intravenously administered over 35 minutes
(range 25 to 45 minutes). It is not necessary to protect the
infusion bags from light while IP is being administered to the
subject. At the site's discretion, the diluted IP may be
administered via gravity feed, a syringe-type pump, or an infusion
pump. The subjects are monitored for 1 hour following infusion.
[0408] If an AE occurs during the administration of the IP, the
infusion may be slowed or stopped at the discretion of the
Investigator, depending upon the nature and severity of the event.
The overall time of infusion should not exceed 2 hours. The AE must
be captured in the subject's source document and CRF.
5. Assessment of Efficacy
[0409] Duration of treatment commences with the first infusion of
IP (eculizumab or placebo). The 26-week Study Period defines the
time period for assessment of the study endpoints (specified in
Table 6, the schedule of assessments). Efficacy will be assessed
comparing eculizumab outcomes to placebo outcomes. Statistical
analyses of the efficacy endpoints are summarized below and
described in more detail in the statistical analysis plan. For all
scales noted below except the EQ Visual Analog Scale (VAS) and
Myasthenia Gravis Foundation of America (MGFA) Post-Intervention
Status (PIS) the higher the score the greater the impairment.
5.1. MG Activities of Daily Living Profile (MG-ADL)
[0410] The MG-ADL is an 8-point questionnaire that focuses on
relevant symptoms and functional performance of activities of daily
living (ADL) in MG subjects (see Table 1). The 8 items of the
MG-ADL were derived from symptom-based components of the original
13-item QMG to assess disability secondary to ocular (2 items),
bulbar (3 items), respiratory (1 item), and gross motor or limb (2
items) impairment related to effects from MG. In this functional
status instrument, each response is graded 0 (normal) to 3 (most
severe). The range of total MG-ADL score is 0-24. A clinically
meaningful improvement in a patient's MG-ADL would be a 3 point or
greater reduction in score after 26 weeks of treatment. The recall
period for MG-ADL is the preceding 7 days. MG-ADL will be performed
at Screening, Day 1, Weeks1-4, 8, 10, 12, 16, 20, and 26 or ET
(Visits 2-6, 8, 10, 12, 14, and 17, or ET) by a properly trained
evaluator, preferably the same evaluator throughout the study.
5.2. QMG Scoring System
[0411] The current QMG scoring system consists of 13 items: ocular
(2 items), facial (1 item), bulbar (2 items), gross motor (6
items), axial (1 item) and respiratory (1 item); each graded 0 to
3, with 3 being the most severe (see Table 2). The range of total
QMG score is 0-39. The QMG scoring system is considered to be an
objective evaluation of therapy for MG and is based on quantitative
testing of sentinel muscle groups. The MGFA task force has
recommended that the QMG score be used in prospective studies of
therapy for MG(15). A clinically meaningful improvement in a
patient's QMG would be a 4 point or greater reduction in score
after 26 weeks of treatment. The QMG will be administered at
Screening, Day 1, Weeks 1-4, 8, 12, 16, 20, and 26 or ET (Visits
1-6, 8, 10, 12, 14, and 17 or ET).
5.3. MGC Score
[0412] The MGC is a validated assessment tool for measuring
clinical status of subjects with MG (16). The MGC assesses 10
important functional areas most frequently affected by MG and the
scales are weighted for clinical significance that incorporate
subject-reported outcomes (see Table 3). A clinically meaningful
improvement in a patient's MGC would be a 3 point or greater
reduction in score after 26 weeks of treatment. MGC will be
administered at Screening, Day 1, Weeks 1-4, 8, 12, 16, 20, and 26
or ET (Visits 1-6, 8, 10, 12, 14, and 17 or ET).
5.4. Quality of Life Assessments 5.4.1. MG-QOL 15
[0413] The 15-item Myasthenia Gravis Qualify of Life scale (MG-QOL
15) (see FIG. 1) is a health-related quality of life evaluative
instrument specific to subjects with MG. MG-QOL15 was designed to
provide information about subjects' perception of impairment and
disability and the degree to which disease manifestations are
tolerated and to be easy to administer and interpret (17). The
MG-QOL 15 is completed by the subject. Higher scores indicate
greater extent of and dissatisfaction with MG-related dysfunction.
A clinically meaningful improvement in a patient's MG-QOL 15 would
be an increase in score after 26 weeks of treatment. The MG-QOL 15
is administered at Screening, Day 1, Weeks 4, 8, 12, 16, 20, and 26
or ET (Visits 1-2, 6, 8, 10, 12, 14, and 17 or ET).
5.4.2. Neuro-QOL Fatigue
[0414] The Neuro-QOL Fatigue is a reliable and validated brief
19-item survey of fatigue, completed by the subject (18). Higher
scores indicate greater fatigue and greater impact of MG on
activities (see Table 5). A clinically meaningful improvement in a
patient's Neuro-QQL Fatigue score would be reflected in a decrease
in score after 26 weeks of treatment. The Neuro-QOL Fatigue is
administered at Day 1, Weeks 4, 8, 12, 16, 20, and 26 or ET (Visits
2, 6, 8, 10, 12, 14, and 17 or ET).
5.4.3. EUROQOL (EQ-5D)
[0415] The EUROQOL (EQ-5D) is a reliable and validated survey of
health status in 5 areas: mobility, self-care, usual activities,
pain/discomfort, and anxiety/depression, completed by the subject
(19). Each area has 3 levels: level 1 (no problems), level 2 (some
problems), and level 3 (extreme problems) (see FIGS. 2A and 2B).
The EQ VAS records the subject's self-rated health on a vertical,
20 cm visual analogue scale where the endpoints are labeled "Best
imaginable health state, marked as 100" and "Worst imaginable
health state, marked as 0." A clinically meaningful improvement in
a patient's EQ-5D would be reflected as an increase in score after
26 weeks of treatment. The EQ-5D is administered at Day 1, Weeks 4,
8, 12, 16, 20, and 26 or ET (Visits 2, 6, 8, 10, 12, 14, and 17 or
ET).
5.5. Other Efficacy Assessments
5.5.1. Negative Inspiratory Force NIF and Forced Vital Capacity
[0416] Subjects with increasingly severe MG can suffer from
potentially fatal respiratory complications including profound
respiratory muscle weakness. Respiratory function is monitored
closely for evidence of respiratory failure in MG subjects and
ventilator support is recommended in the event of consistent
declines in serial measurements of Forced Vital Capacity (FVC) or
Negative Inspiratory Force (NIF), loss of upper airway integrity
(difficulty handling oral secretions, swallowing, or speaking) or
in the setting of emerging respiratory failure. FVC as one of the
test items in QMG is performed when QMG is performed. NIF was to be
performed using the NIF Meter. It is measured at Screening, Day 1,
Weeks 1-4, 8, 12, 16, 20, and 26 or ET (Visits 1-6, 8, 10, 12, 14,
and 17 or ET).
5.5.2. MGFA Post-Intervention Status
[0417] The MG clinical state is assessed using the MGFA
Post-Intervention Status. See Table 10. Change in status categories
of Improved, Unchanged, Worse, Exacerbation and Died of MG as well
as the Minimal manifestation (MM) is assessed and recorded at Weeks
4, 12 and 26 or ET (Visits 6, 10 and 17 or ET) by the PI or the
same neurologist skilled in the evaluation of MG subjects
throughout the trial. The sub-scores of MM, i.e., MM-0, MM-1, and
MM-3, will not be used in this protocol.
6.2. Determination of Sample Size
[0418] The study design is a randomized, double blind,
placebo-controlled design. Subjects will be randomly assigned 1:1
to eculizumab or placebo. The randomization stratification variable
will be based on MG clinical classification by the Myasthenia
Gravis Foundation of America (MGFA) according to the following 4
groupings (Class IIa and IIIa, Class IVa, Class IIb and IIIb and
Class IVb).
[0419] The sample size and power calculation assumptions are as
follows: [0420] 1:1 randomization (eculizumab: placebo) [0421]
Power 90% for both the primary and the first secondary endpoints
[0422] Two-sided 5% level of significance [0423] Drop-out rate 15%
[0424] Mean changes from baseline for MG-ADL are assumed to be 4
for eculizumab and 1.5 for placebo with a standard deviation of
3.25, mean changes in QMG total score of 7 for eculizumab and 3 for
placebo with a standard deviation of 6, and mean ranked differences
between the treatment groups is assumed to be 3 with a standard
deviation of 4 for both endpoints. Sample size calculations based
on t-test.
[0425] With these assumptions, a sample size of approximately 92
subjects (46 eculizumab and 46 placebos) provides 90% power to
detect a treatment difference at 26 weeks.
6.3. Analyses Sets
[0426] Analyses are produced for the double-blind Study Period in
order to compare the eculizumab group with placebo group. The
analyses include efficacy, safety, and PK/PD analyses.
6.3.1. Full Analysis Set
[0427] The full analysis set (FAS) is the population on which
primary, secondary, and tertiary efficacy analyses is performed and
consists of all subjects who are randomized to IP and who have
received at least 1 dose of IP (eculizumab or placebo treatment)
and have at least one efficacy assessment post IP infusion.
Subjects are compared for efficacy according to the treatment they
were randomized to receive, irrespective of the treatment they
actually received.
6.3.2. Per-Protocol Set
[0428] The Per-Protocol (PP) Set is a subset of the Full Analysis
Set (FAS) population, excluding subjects with major protocol
deviations. The possible categories of major protocol deviations
are defined in the statistical analysis plan. The per-protocol
population will include all subjects who: [0429] Have no major
protocol deviations or inclusion/exclusion criteria deviations that
might potentially affect efficacy, [0430] Subjects who took at
least 80% of the required doses and remained enrolled in the trial
for 26 weeks or subjects who took at least 80% of the required
doses up to the time of being discontinued for Clinical
Deterioration (e.g., MG crisis/exacerbation).
[0431] The PP population will be fully described in the statistical
analysis plan, and subjects identified prior to database lock.
Efficacy analyses will also be performed on the PP data set.
6.7. Efficacy Analyses
[0432] Note: During the Study Period, Baseline is defined as the
last available assessment prior to treatment for all subjects,
regardless of treatment group.
6.7.1. Primary Efficacy Endpoint
[0433] The primary efficacy endpoint is change from baseline in the
MG-ADL total score at Week 26 of the Study Period. The primary
efficacy analysis is conducted on the available 26 week data from
the Study Period for all subjects. The trial is considered to have
met its primary efficacy objective if a statistically significant
difference (p.ltoreq.0.05) between the eculizumab treatment group
and placebo group is observed for change from baseline in the
MG-ADL total score at Week 26. Confidence intervals and p-values
will be presented. For the primary analysis concerning the change
from baseline in the MG-ADL total score at Week 26, treatment
groups are compared using a worst-rank score analysis (i.e.,
analysis of covariance [ANCOVA] analysis with ranks) with effects
for treatment. The baseline MG-ADL total score and the
randomization stratification variables are also to be covariates in
the model. In this analysis, the actual changes from baseline are
ranked from highest (best improvement in MG-ADL score) to lowest
(least improvement/most worsening in MG-ADL score) across all
subjects who did not need rescue therapy. Then, any subject who
needed rescue therapy would be given lower ranks. These lower ranks
are based on the time to rescue therapy from the start of
investigational product (Day 1). The subject with the shortest time
to rescue therapy would get the absolute lowest rank in the
analysis and the subject with the longest time to rescue therapy
would get a rank that is one lower than the lowest ranked subject
without rescue therapy. Last observation carried-forward is used
for missing changes from baseline at Week 26 for patients with
missing Week 26 who did not require rescue therapy.
[0434] A sensitivity analysis for the actual change from baseline
in the MG-ADL total score at Week 26 is also performed. Treatment
groups are compared using ANCOVA analysis using the actual change
from baseline in the MG-ADL total score at Week 26 with effects for
treatment. The baseline MG-ADL total score and the randomization
stratification variable are also covariates in the model. Last
observation carried-forward is used for missing changes from
baseline at Week 26.
[0435] A sensitivity analysis for the actual change from baseline
in the MG-ADL total score at Week 26 is also performed. In the
sensitivity analysis, treatment groups are compared using repeated
measures model with effects for treatment and visits. The baseline
MG-ADL total score, the randomization stratification variable, and
an indicator for the IST treatment status of the subject are also
covariates in the model. Subjects have an IST treatment status
variable defined based on the IST treatments the subject
receives.
[0436] In addition, summaries of changes from baseline in the
MG-ADL total score at Week 26 are produced by treatment group for
subjects who have failed ISTs. [0437] Subjects who have failed
treatment over one year or more with 2 or more ISTs in sequence or
in combination. [0438] Subjects who have failed at least one IST
and require chronic plasma exchange or IVIg to control
symptoms.
6.7.2. Secondary Efficacy Analysis
[0439] Unless otherwise specified, the secondary efficacy analyses
use the available 26-week data from the Study Period. Hypothesis
testing comparing eculizumab treatment with placebo treatment for
the secondary efficacy analyses are performed using a closed
testing procedure with the following rank order: [0440] 1. Change
from baseline in QMG total score at Week 26 [0441] 2. Proportion of
subjects with at least a 3-point reduction in the MG-ADL total
score from baseline to Week 26 and with no rescue therapy [0442] 3.
Proportion of subjects with at least a 5-point reduction in the QMG
total score from baseline to Week 26 and with no rescue therapy
[0443] 4. Change from baseline in the MGC score at Week 26 [0444]
5. Change from baseline in MG-QOL15 at Week 26
[0445] The hypothesis testing will proceed from highest rank (#1)
Change from baseline in QMG total score at Week 26 to (#5) Change
from baseline in MG-QOL-15, and if statistical significance is not
achieved at an endpoint (p.ltoreq.0.05), then endpoints of lower
rank are not considered to be statistically significant. Confidence
intervals and p-values are presented for all secondary efficacy
endpoints for descriptive purposes, regardless of the outcome of
the closed testing procedure.
[0446] The secondary endpoints that involve changes from baseline
are analyzed using a worst-case ranked analysis of covariance
(ANCOVA) like that described for the primary efficacy endpoints as
the primary analysis for the particular secondary endpoint. The
ranked ANCOVA will have effects for treatment, the baseline for the
particular endpoint, and the randomization stratification
variable.
[0447] A sensitivity analysis for the change from baseline in QMG
at Week 26 is analyzed using repeated measures model with effects
for treatment, visits, and baseline QMG score in order to compare
treatment groups. The randomization stratification variable is also
a covariate in the model. A sensitivity analysis for the actual
change from baseline in QMG score at Week 26 will also be
performed. Treatment groups are compared using ANCOVA analysis
using the actual change from baseline in the QMG score at Week 26
with effects for treatment. The baseline QMG score and the
randomization stratification variable are also covariates in the
model. Last observation carried-forward will be used for missing
changes from baseline at Week 26.
[0448] A sensitivity analysis for the change from baseline in MGC
at Week 26 is analyzed using repeated measures model with effects
for treatment, visits, and baseline MGC score in order to compare
treatment groups. The randomization stratification variable is also
a covariate in the model.
[0449] A sensitivity analysis for the change from baseline in
MG-QOL-15 at Week 26 is analyzed using repeated measures model with
effects for treatment, visits, and baseline MG-QOL-15 score in
order to compare treatment groups. The randomization stratification
variable is also a covariate in the model.
[0450] The proportion of subjects with at least a 3 point reduction
in the MG-ADL total score from baseline to Week 26 with no rescue
therapy are analyzed by the Cochran-Mantel-Haenszel test stratified
by randomization stratification variable in order to compare
eculizumab versus placebo.
[0451] The proportion of subjects with at least a 5 point reduction
in the QMG total score from baseline to Week 26 with no rescue
therapy are analyzed by the Cochran-Mantel-Haenszel test stratified
by randomization stratification variable in order to compare
eculizumab versus placebo.
[0452] Additional sensitivity analyses are performed in order that
assess the impact of IST treatment status on the various secondary
endpoints. A sensitivity analysis for the change from baseline in
the secondary endpoints (i.e., QMG, MGC, and MG-QOL-15) at Week 26
are analyzed using repeated measures model with effects for
treatment, visits, and baseline score in order to compare treatment
groups. The randomization stratification variable and an indicator
for the IST treatment status of the subject are also covariates in
the model. Subjects will have an IST treatment status variable
defined based on the IST treatments the subject receives.
[0453] In addition, summaries of changes from baseline in QMG, MGC,
and MG-QOL-15 at Week 26 are produced by treatment group for
subjects who have failed ISTs. [0454] Subjects who have failed
treatment over one year or more with 2 or more ISTs in sequence or
in combination [0455] Subjects who have failed at least one IST and
require chronic plasma exchange or IVIg to control symptoms.
6.7.3. Tertiary Efficacy Endpoints
[0456] The tertiary efficacy analyses for the Study Period include
the following: [0457] 1. Time to response as measured by the
reduction in the MG-ADL total score (3-point reduction from
baseline) [0458] 2. Change from baseline in Neuro-QOL Fatigue at
Week 26 [0459] 3. Change from baseline in EQ-5D at 26 weeks [0460]
4. Change from baseline in NIF at Week 26 in subjects with abnormal
NIF at baseline [0461] 5. Change from baseline in FVC at Week 26 in
subjects with abnormal FVC at baseline [0462] 6. Change from
baseline in the MG-ADL individual items and change from baseline in
the MG-ADL sub-categories for the bulbar (items 1, 2 and 3),
respiratory (item 4), limb (items 5 and 6) and ocular (items 7 and
8) at Week 26 in subjects with an abnormal baseline score for the
particular item or sub-category [0463] 7. Change from baseline in
the MGFA Post-Intervention Status at Week 26.
[0464] For the time to response on the MG-ADL total score (3-point
reduction in MG-ADL from baseline), treatment groups are compared
using Cox PH regression with robust variance estimation. The
randomization stratification variable is also a covariate in the
model. Inference is based on the Wald test of the log hazard
ratio.
[0465] Quality of life is summarized as appropriate to the quality
of life instrument and treatment group comparisons is performed as
specified in the statistical analysis plan (SAP).
[0466] The tertiary endpoints that involve changes from baseline
are analyzed using a worst-case ranked ANCOVA like that described
for the primary efficacy endpoints as the primary analysis for the
particular tertiary endpoint. The ranked ANCOVA has effects for
treatment, the baseline for the particular endpoint, and the
randomization stratification variable.
[0467] A sensitivity analysis for the change from baseline in NIF
at Week 26 for subjects with abnormal NIF at baseline is analyzed
using repeated measures model with effects for treatment, visits,
and baseline NIF in order to compare treatment groups. The
randomization stratification variables are also covariates in the
model.
[0468] A sensitivity analysis for the change from baseline in FVC
is analyzed using repeated measures model with effects for
treatment, visits, and baseline FVC in order to compare treatment
groups. The randomization stratification variable is also a
covariate in the model.
[0469] A sensitivity analysis for the change from baseline in the
MG-ADL individual items and sub-categories at Week 26 in subjects
that are abnormal at baseline are analyzed using repeated measures
model with effects for treatment, visits, and baseline MG-ADL
individual item and sub-categories, as applicable for the analysis,
in order to compare treatment groups. The randomization
stratification variable is also a covariate in the model. In
addition, for all full analysis set (FAS) and all PP subjects, a
sensitivity analysis for the change from baseline in the MG-ADL
individual items and sub-categories at Week 26 are performed using
repeated measures model with effects for treatment, visits, and
baseline MG-ADL individual item or sub-categories score, as
applicable for the analysis, in order to compare treatment groups.
The randomization stratification variable is also a covariate in
the model. Finally, similar sensitivity analyses and/or summaries
are produced (depending on the number of subjects) in the subset of
subjects who were normal at baseline and became abnormal after
baseline in the MG-ADL individual items and sub-categories.
[0470] A summary of subjects going from normal to abnormal for NIF
and FVC are presented. A summary of subjects going from normal to
abnormal for a particular MG-ADL individual items and
sub-categories are produced.
6.11. Other Statistical Issues
6.11.1. Significance Levels
[0471] For all analyses, the eculizumab treated group is compared
to the placebo group and all hypothesis testing is two-sided and
performed at the 0.05 level of significance, unless otherwise
specified. Estimates of treatment effect on efficacy parameters are
accompanied by two-sided 95% confidence intervals for the effect
size.
6.11.2. Missing or Invalid Data
[0472] For efficacy and safety analyses, missing post-baseline
efficacy and safety data are not imputed unless indicated in the
described analysis in the SAP.
6.11.3. Interim Analysis
[0473] There is no interim analysis planned for this trial.
Example 2
Extension Trial
[0474] An extension trial is described herein that was run to
evaluate the long-term safety of eculizumab in subjects with
refractory gMG. Other secondary objectives include: [0475]
Evaluation of the long-term efficacy as measured by MG-ADL [0476]
Evaluation of long-term efficacy by additional efficacy measures
including: [0477] QMG, MGC, [0478] MG-ADL individual items and
subcategories [0479] Quality of life
Description of the PK and PD of Eculizumab in Refractory gMG
Patients.
[0480] The extension trial lasts for 4 years (FPFV to LPLV). The
first visit occurs within 2 weeks of Visit 17 (Week 26) in the
trial described above. To maintain the blind of the previous trial,
all subjects undergo a blind induction phase, followed by an open
label maintenance phase. This is summarized in FIGS. 6 and 7. "Home
infusion" at selected visits is performed with permission of the
primary investigator in accordance with regulations. Assessments,
Treatment, Concomitant/Prohibited medications were performed as in
the study described above.
[0481] The inclusion criteria for the extension trial was
completion of the previous trial. Exclusion criteria were
withdrawing from the previous trial and pregnancy or intention to
get pregnant. IST treatment could be changed at the treating
physician's discretion but rituximab was prohibited.
[0482] Efficacy was measured by MG-ADL, QMG, MGC, NIF, FVC, QOL,
G-QOL15, Neuro-QOL Fatigue, EQ-5D and MGFA Post-Intervention
Status.
Example 3
Results from REGAIN Study Comprising ECU-MG-301 26 Week (301) Trial
and ECU-MG-302 Extension (302) Trial
[0483] The REGAIN study is a randomized, double-blind,
placebo-controlled, multicenter trial evaluating the safety and
efficacy of eculizumab in patients with refractory gMG. The study
enrolled and treated 125 adult patients across North America, South
America, Europe, and Asia. Patients had a confirmed MG diagnosis
with positive serologic test for anti-AChR antibodies. All patients
had previously failed treatment with at least two immunosuppressive
agents or failed treatment with at least one immunosuppressive
agent and required chronic plasma exchange or IVIg, and had an
MG-ADL total score .gtoreq.6 at study entry.
[0484] As discussed above the patients were initially randomized
according to MGFA Clinical Classification shown in Table 7 into the
following four groups:
[0485] MGFA IIa/IIIa
[0486] MGFA
[0487] MGFA IVa
[0488] MGFA IVb
[0489] The breakdown of the MGFA classification at screening was as
follows: Class IIa 25 total patients; Class IIb 22 total patients;
Class IIIa 36 total patients; Class IIIb 30 total patients; Class
IVa 6 total patients; and Class IVb 6 total patients.
[0490] The patients were assigned to the placebo group as follows:
Class IIa 15 (23.8%) total patients; Class IIb 14 (22.2%) total
patients; Class IIIa 16 (25.4%) total patients; Class IIIb 13
(20.6%) total patients; Class IVa 2 (3.2%) total patients; and
Class IVb 3 (4.8%) total patients.
[0491] The patients were assigned to the eculizumab group were as
follows: Class IIa 10 (16.1%) total patients; Class IIb 8 (12.9%)
total patients; Class IIIa 20 (32.3%) total patients; Class IIIb 17
(27.4%) total patients; Class IVa 4 (6.5%) total patients; and
Class IVb 3 (4.8%) total patients.
[0492] The disposition of patients completing the 301 trial and
entering the 302 trial is shown below in Table 14.
TABLE-US-00013 TABLE 14 PATIENT DISPOSITION IN THE 301 AND 302
TRIALS Placebo Eculizumab Total Status n (%) n (%) n (%) Randomized
63 (100.0) 63 (100.0) 126 (100.0) Treated 63 (100.0) 62 (98.4) 125
(99.2) Completed the Study 61 (96.8) 57 (90.5) 118 (93.7)
Discontinued 2 (3.2) 6 (9.5) 8 (6.3) Adverse Event 0 (0.0) 4 (6.3)
4 (3.2) Death 0 (0.0) 0 (0.0) 0 (0.0) Withdrawal by Subject 2 (3.2)
1 (1.6) 3 (2.4) Other 0 (0.0) 1 (1.6) 1 (0.8) Enrolled in
Open-Label 61 (96.8) 56 (88.9) 117 (92.9) Extension Study
[0493] Therefore 96.8% of the placebo patients and 88.9% of the
eculizumab patients proceeded into the extension trial.
[0494] The demographics of the 301 trial participants were as is
shown below in Table 15.
TABLE-US-00014 TABLE 15 DEMOGRAPHICS OF 301 CLINICAL TRIAL
PARTICIPANTS Placebo Eculizumab Total Variable Statistic (N = 63)
(N = 62) (N = 125) Age at First IP n 63 62 125 Dose (years) (1)
Mean 46.9 (17.98) 47.5 (15.66) 47.2 (16.80) (SD) Median 48.0 44.5
46.0 Min, Max 19, 79 19, 74 19, 79 Sex Male n (%) 22 (34.9) 21
(33.9) 43 (34.4) Female n (%) 41 (65.1) 41 (66.1) 82 (65.6) Race
Asian n (%) 16 (25.4) 3 (4.8) 19 (15.2) Black or African n (%) 3
(4.8) 0 (0.0) 3 (2.4) American White n (%) 42 (66.7) 53 (85.5) 95
(76.0) Other n (%) 2 (3.2) 6 (9.7) 8 (6.4) Is the subject of
Japanese descent? Yes n (%) 9 (14.3) 3 (4.8) 12 (9.6) No n (%) 54
(85.7) 59 (95.2) 113 (90.4)
[0495] The protocol defines clinical deterioration as a subject who
has one of the following: [0496] 1. MG Crisis [0497] 2. Significant
symptomatic worsening, defined as worsening on any one of the
MG-ADL individual items excluding ocular (i.e., talking, chewing,
swallowing, breathing, upper and lower extremity weakness): [0498]
To Grade 3, or [0499] 2-point worsening in MG-ADL [0500] 3. The
treating physician believes that the subject's health is in
jeopardy if rescue therapy is not administered.
[0501] Rescue therapy is defined in the protocol as follows: Use of
PE or IVIg will be allowed for subjects who experience a Clinical
Deterioration as defined by this protocol. The rescue therapy used
for a particular subject is at the discretion of the treating
physician
[0502] If PE is administered as a rescue therapy, supplemental IP
(2 vials) are administered within 60 minutes after the end of each
PE session. Routine (per protocol schedule) IP administration is
continued per the specified dose-administration schedule for the
subject. If the subject is scheduled to receive the
protocol-scheduled dose on the day of a PE session, then the
scheduled dose is administered within 60 minutes after the end of
the PE session.
[0503] The total numbers of patients who experienced clinical
deterioration during the protocol were as is shown below in Table
16.
TABLE-US-00015 TABLE 16 CLINICAL DETERIORATION DURING THE 301
Placebo Eculizumab Variable Statistic (N = 63) (N = 62) Total
Number of Subjects Reporting n (%) 15 (23.8) 6 (9.7) Clinical
Deterioration Total Number of Subjects n (%) 11 (17.5) 6 (9.7)
Experiencing Clinical Deterioration Per Protocol Criteria Total
Number of Subjects Experiencing the Following Events: MG Crisis n
(%) 0 (0.0) 1 (1.6) Significant symptomatic worsening n (%) 9
(14.3) 4 (6.5) Subject's health is in jeopardy n (%) 3 (4.8) 2
(3.2) Other n (%) 4 (6.3) 0 (0.0) Total Number of Clinical n 27 13
Deterioration Events: MG Crisis n 0 1 Significant symptomatic
worsening n 14 4 Subject's health is in jeopardy n 7 8 Other n 6
0
[0504] The clinical deteriorations requiring rescue therapy are
shown in Table 17 below:
TABLE-US-00016 TABLE 17 CLINICAL DETERIORATION REQUIRING RESCUE
THERAPIES DURING THE 301 Placebo Eculizumab Variable Statistic (N =
63) (N = 62) Total Number of Subjects Requiring n (%) 12 (19.0) 6
(9.7) Rescue Therapy: Total Number of Subjects Requiring n (%) 5
(7.9) 0 (0.0) High Dose Corticosteroids Total Number of Subjects
Requiring n (%) 4 (6.3) 3 (4.8) Plasmapheresis/Plasma Exchange
Total Number of Subjects Requiring n (%) 6 (9.5) 4 (6.5) IVIg Total
Number of Subjects Requiring n (%) 2 (3.2) 1 (1.6) Other Rescue
Therapy Total Number of Clinical n 24 13 DeteriorationEvents
Requiring Rescue Therapy: Total Number of Clinical n 8 0
Deterioration Events Requiring High Dose Corticosteriods Total
Number of Clinical n 10 4 Deterioration Events Requiring
Plasmapheresis/Plasma Exchange Total Number of Clinical n 13 10
Deterioration Events Requiring IVIg Total Number of Clinical n 2 2
Deterioration Events Requiring Other Rescue Therapy
The primary and secondary endpoints as described above were used as
shown below: [0505] Primary Endpoint: [0506] Change from baseline
in MG-ADL Total Score at Week 26 [0507] Secondary Endpoints
(hierarchal): [0508] Change from baseline in QMG Total Score at
Week 26 [0509] Proportion of subjects with .gtoreq.3-point
reduction in MG-ADL Total Score from baseline to Week 26 and
without rescue therapy [0510] Proportion of subjects with
.gtoreq.5-point reduction in QMG Total Score from baseline to Week
26 and without rescue therapy [0511] Change from baseline in the
Myasthenia Gravis Composite (MGC) Total Score at Week 26 [0512]
Change from baseline in MG-QoL15 at Week 26
[0513] One primary endpoint in the MG-ADL score at week 26. The
score ranges from 0-24 and contains 3 bulbar items, 1 respiratory
item, 2 gross motor or limb items, and 2 ocular items. A clinically
meaningful improvement in MG-ADL is defined as a 3 points or
greater reduction. See Table 1.
TABLE-US-00017 TABLE 18 MG-ADL WORST RANK ANALYSIS: SAP3 PER
PROTOCOL SET Difference in LS Placebo Eculizumab Means and Variable
Statistic (N = 56) (N = 54) 95% CI p-value Worst Ranked Change
Ranked Score 61.3 (4.10) 48.4 (4.20) -12.8 0.0305 from Baseline LS
Mean (SEM) 95% CI for (53.15, (40.11, (-24.46, LS Mean 69.39)
56.74) -1.24) Baseline MG-ADL n 48 49 Total Score for patients Mean
(SD) 9.8 (2.70) 10.1 (3.07) not needing rescue Median 9.0 10.0
therapy or dropping Min, Max 5, 18 5, 18 out of the study Week 26
MG-ADL n 48 49 Total Score (LOCF) Mean (SD) 7.0 (3.37) 5.5 (4.04)
for patients not Median 6.0 5.0 needing rescue therapy Min, Max 2,
16 0, 15 or dropping out of the study Change from Baseline n 48 49
to Week 26 in MG- Mean (SD) -2.8 (3.05) -4.7 (4.35) ADL Total Score
for Median -2.0 -4.0 patients not needing Min, Max -8, 7 -15, 4
rescue therapy or dropping out of the study
[0514] The results from the patients who finished the entire
protocol are shown in Table 18. Therefore, as shown in Table 20 the
median value for the eculizumab group showed a -4 reduction in
MG-ADL. This result demonstrates eculizumab produced a clinically
meaningful improvement in MG patients as measured by their MG-ADL
score.
[0515] The data were analyzed in multiple ways for statistical
purposes as shown in Tables 18, 19, 20, and 21, but in each case
the eculizumab group produced clinically meaningful improvement in
MG-ADL and the placebo group failed to produce clinically
meaningful improvement in MG-ADL. See Tables 18-21.
TABLE-US-00018 TABLE 19 MG-ADL WORST RANK ANALYSIS: SAP3 FULL
ANALYSIS SET Difference in LS Placebo Eculizumab Means and Variable
Statistic (N = 56) (N = 54) 95% CI p-value Worst Ranked Change
Ranked Score 68.3 (4.49) 56.6 (4.53) -11.7 0.0698 from Baseline LS
Mean (SEM) 95% CI for (59.43, (47.66, (-24.33, LS Mean 77.20)
65.61) 0.96) Baseline MG-ADL n 51 52 Total Score for patients Mean
(SD) 9.9 (2.64) 10.1 (3.00) not needing rescue Median 9.0 10.0
therapy or dropping Min, Max 5, 18 5, 18 out of the study Week 26
MG-ADL n 51 52 Total Score (LOCF) Mean (SD) 7.0 (3.36) 5.4 (4.05)
for patients not Median 6.0 5.0 needing rescue therapy Min, Max 2,
16 0, 15 or dropping out of the study Change from Baseline n 51 52
to Week 26 in MG- Mean (SD) -2.8 (3.07) -4.7 (4.32) ADL Total Score
for Median -2.0 -4.5 patients not needing Min, Max -8, 7 -15, 4
rescue therapy or dropping out of the study
[0516] Refractory gMG is an ultra-rare segment of MG--a
debilitating, complement-mediated neuromuscular disease--in which
patients have largely exhausted conventional therapy and continue
to suffer profound muscle weakness throughout the body, resulting
in slurred speech, impaired swallowing and choking, double vision,
upper and lower extremity weakness, disabling fatigue, shortness of
breath due to respiratory muscle weakness, and episodes of
respiratory failure. In the study, the primary efficacy endpoint of
change from baseline in Myasthenia Gravis-Activities of Daily
Living Profile (MG-ADL) total score, a patient-reported assessment,
at week 26, did not reach statistical significance (p=0.0698) as
measured by a worst-rank analysis.
TABLE-US-00019 TABLE 20 MG-ADL ANCOVA ACTUAL CHANGES FULL ANALYSIS
SET Difference in LS Placebo Eculizumab Means and Variable
Statistic (N = 56) (N = 54) 95% CI p-value Change LS Mean -2.6
(0.48) -4.0 (0.48) -1.4 0.0390 from (SEM) Baseline 95% CI for
(-3.52, (-4.96, (-2.77, LS Mean -1.63) -3.04) -0.07) Baseline n 63
62 MG-ADL Mean (SD) 9.9 (2.58) 10.5 (3.06) Total Score Median 9.0
10.0 Min, Max 5, 18 5, 18 Week 26 n 63 62 MG-ADL Mean (SD) 7.4
(3.50) 6.4 (4.76) Total Score Median 7.0 6.0 (LOCF) Min, Max 0, 16
0, 17 Change n 63 62 from Mean (SD) -2.4 (3.32) -4.1 (4.48)
Baseline Median -2.0 -4.0 Min, Max -8, 7 -15, 4
TABLE-US-00020 TABLE 21 MG-ADL ANCOVA ACTUAL CHANGES PER PROTOCOL
SET Difference in LS Placebo Eculizumab Means and Variable
Statistic (N = 56) (N = 54) 95% CI p-value Change LS Mean -2.6
(0.48) -4.3 (0.49) -1.7 0.0153 from (SEM) Baseline 95% CI for
(-3.54, (-5.25, (-3.05, LS Mean -1.63) -3.30) -0.33) Baseline n 56
54 MG-ADL Mean (SD) 9.9 (2.63) 10.3 (3.04) Total Score Median 9.0
10.0 Min, Max 5, 18 5, 18 Week 26 n 56 54 MG-ADL Mean (SD) 7.4
(3.39) 6.0 (4.36) Total Score Median 7.0 6.0 (LOCF) Min, Max 2, 16
0, 17 Change n 56 54 from Mean (SD) -2.4 (3.16) -4.3 (4.47)
Baseline Median -2.0 -4.0 Min, Max -8, 7 -15, 4
[0517] Next the QMG scores were evaluated for all study
participants. The current QMG scoring system consists of 13 items:
ocular (2 items), facial (1 item), bulbar (2 items), gross motor (6
items), axial (1 item) and respiratory (1 item); each graded 0 to
3, with 3 being the most severe (see Table 2). The range of total
QMG score is 0-39. The QMG scoring system is considered to be an
objective evaluation of therapy for MG and is based on quantitative
testing of sentinel muscle groups. The MGFA task force has
recommended that the QMG score be used in prospective studies of
therapy for MG. A clinically meaningful improvement in a patient's
QMG would be a 5 point or greater reduction in score after 26 weeks
of treatment.
[0518] The QMG score for the full data set was -5 in the eculizumab
treated group and therefore resulted in a clinically significant
improvement for all patients not needing rescue or dropping out of
the study. See Table 22 below and FIG. 11 for the results.
TABLE-US-00021 TABLE 22 QMG WORST RANK ANALYSIS: SAP3 FULL ANALYSIS
SET Difference in LS Placebo Eculizumab Means and Variable
Statistic (N = 56) (N = 54) 95% CI p-value Worst Ranked Change
Ranked Score 70.7 (4.46) 54.7 (4.50) -16.0 0.0129 from Baseline LS
Mean (SEM) 95% CI for (61.85, (45.82, (-28.48, LS Mean 79.51)
63.64) -3.43) Baseline QMG Total n 51 52 Score for patients not
Mean (SD) 16.4 (5.76) 17.1 (4.96) needing rescue therapy Median
15.0 17.0 or dropping out of the Min, Max 8, 34 6, 31 study Week 26
QMG Total n 51 52 Score (LOCF) for Mean (SD) 14.1 (5.40) 11.7
(5.83) patients not needing Median 13.0 12.0 rescue therapy or Min,
Max 5, 32 1, 27 dropping out of the study Change from Baseline n 51
52 to Week 26 in QMG Mean (SD) -2.4 (3.70) -5.4 (4.80) Total Score
for patients Median -3.0 -5.0 not needing rescue Min, Max -11, 8
-16, 2 therapy or dropping out of the study
[0519] Next, the MGC score was evaluated for all study participants
over time. The MGC is a validated assessment tool for measuring
clinical status of subjects with MG (16). The MGC assesses 10
important functional areas most frequently affected by MG and the
scales are weighted for clinical significance that incorporate
subject-reported outcomes (see Table 3). MGC will be administered
at Screening, Day 1, Weeks 1-4, 8, 12, 16, 20, and 26 or ET (Visits
1-6, 8, 10, 12, 14, and 17 or ET). Total scores range from 0-50. A
clinically meaningful improvement in a patient's MGC would be a 3
point or greater reduction in score after 26 weeks of
treatment.
TABLE-US-00022 TABLE 23 MG COMPOSITE WORST RANK ANALYSIS: SAP3 FULL
ANALYSIS SET Difference in LS Placebo Eculizumab Means and Variable
Statistic (N = 56) (N = 54) 95% CI p-value Worst Ranked Change
Ranked Score 67.7 (4.47) 57.3 (4.52) -10.5 0.1026 from Baseline LS
Mean (SEM) 95% CI for (58.89, (48.32, (-23.07, LS Mean 76.57)
66.21) 2.13) Baseline MGC Total n 51 52 Score for patients not Mean
(SD) 19.0 (6.19) 19.4 (5.97) needing rescue therapy Median 19.0
20.0 or dropping out of the Min, Max 7, 40 7, 35 study Week 26 MGC
Total n 51 52 Score (LOCF) for Mean (SD) patients not needing
Median 13.0 (6.96) 10.3 (7.00) rescue therapy or Min, Max 12.0 9.5
dropping out of the 3, 37 0, 28 study Change from Baseline n 51 52
to Week 26 in MGC Mean (SD) -6.0 (6.19) -9.2 (8.08) Total Score for
patients Median -6.0 -10.0 not needing rescue Min, Max -21, 13 -24,
17 therapy or dropping out of the study
[0520] The MGC score for the full data set was (-10) in the
eculizumab treated group and therefore resulted in a clinically
significant improvement for all patients not needing rescue or
dropping out of the study. See Table 23 above for the results.
[0521] The 15-item Myasthenia Gravis Qualify of Life scale (MG-QOL
15) is a health-related quality of life evaluative instrument
specific to subjects with MG. See Table 4. MG-QOL15 was designed to
provide information about subjects' perception of impairment and
disability and the degree to which disease manifestations are
tolerated and to be easy to administer and interpret. The MG-QOL 15
is completed by the subject. Total scores range from 0 to 60 and
higher scores indicate greater extent of and dissatisfaction with
MG-related dysfunction. A clinically meaningful improvement in a
patient's MGQOL would be a decrease in score after 26 weeks of
treatment.
[0522] The MG-QOL15 median score for the full data set was (-11.5)
in the eculizumab treated group and therefore resulted in a
clinically significant improvement for all patients not needing
rescue or dropping out of the study. See Table 24 below for the
results.
TABLE-US-00023 TABLE 24 MG-QOL15 WORST RANK ANALYSIS FULL ANALYSIS
SET Difference in LS Placebo Eculizumab Means and Variable
Statistic (N = 56) (N = 54) 95% CI p-value Worst Ranked Change
Ranked Score 69.7 (4.51) 55.5 (4.55) -14.3 0.0281 from Baseline LS
Mean (SEM) 95% CI for (60.79, (46.43, (-26.98, LS Mean 78.66)
64.47) -1.56) Baseline MG-QOL15 n 51 52 Total Score for patients
Mean (SD) 30.2 (13.10) 31.5 (11.82) not needing rescue Median 30.0
32.0 therapy or dropping out Min, Max 6, 60 6, 59 of the study Week
26 MG-QOL15 n 51 52 Total Score (LOCF) for Mean (SD) 23.7 (13.38)
18.0 (14.37) patients not needing Median 20.0 16.0 rescue therapy
or Min, Max 3, 58 0, 59 dropping out of the study Change from
Baseline n 51 52 to Week 26 in MG- Mean (SD) -6.5 (9.40) -13.5
(14.07) QOL15 Total Score for Median -6.0 -11.5 patients not
needing Min, Max -30, 16 -44, 19 rescue therapy or dropping out of
the study
[0523] The Neuro-QOL Fatigue is a reliable and validated brief
19-item survey of fatigue completed by the subject. Higher scores
indicate greater fatigue and greater impact of MG on activities
(see Table 5). A clinically meaningful improvement in a patient's
Neuro-QQL Fatigue score would be reflected in a decrease in score
after 26 weeks of treatment.
[0524] As shown in Table 25 below, the eculizumab treated group
realized a clinically meaningful improvement (reduction) in their
Neuro-QQL Fatigue score after 26 weeks of treatment.
TABLE-US-00024 TABLE 25 NEURO FATIGUE QOL WORST RANK ANALYSIS FULL
ANALYSIS SET Difference in LS Placebo Eculizumab Means and Variable
Statistic (N = 56) (N = 54) 95% CI p-value Worst Ranked Change
Ranked Score 74.1 (6.26) 58.5 (6.06) -15.6 0.0145 from Baseline LS
Mean (SEM) 95% CI for (61.73, (46.49, (-28.13, LS Mean 86.53)
70.48) -3.15) Baseline Neuro-QOL n 49 51 Fatigue Total Score for
Mean 61.7 (15.36) 61.8 (13.57) patients not needing Median 65.0
62.0 rescue therapy or Min, Max 29, 88 36, 92 dropping out of the
study Week 26 Neuro-QOL n 49 51 Fatigue Total Score Mean (SD) 52.6
(18.66) 43.6 (19.44) (LOCF) for patients not Median 55.0 38.0
needing rescue therapy Min, Max 21, 85 19, 95 or dropping out of
the study Change from Baseline n 49 51 to Week 26 in Neuro- Mean
(SD) -9.1 (14.58) -18.2 (19.60) QOL Fatigue Total Median -8.0 -16.0
Score for patients not Min, Max -51, 20 -59, 30 needing rescue
therapy or dropping out of the study
Discussion of the Significance of the REGAIN Study
[0525] The first prospectively defined secondary efficacy endpoint
of change from baseline in Quantitative Myasthenia Gravis (QMG)
total score, a physician-administered assessment of MG clinical
severity, with eculizumab treatment compared to placebo at week 26,
achieved a p-value of 0.0129 as measured by a worst-rank analysis.
In addition, the second and third prospectively defined secondary
efficacy endpoints of responder status in MG-ADL and QMG achieved
p-values of <0.05: the proportion of patients with at least a
3-point reduction in MG-ADL total score and no rescue therapy from
baseline to week 26 with eculizumab treatment, compared to placebo,
achieved a p-value of 0.0229, and the proportion of patients with
at least a 5-point reduction in QMG total score and no rescue
therapy from baseline to week 26 with eculizumab treatment compared
to placebo achieved a p-value of 0.0018.
[0526] It is encouraging that the REGAIN study achieved clinically
meaningful improvements in MG-ADL and QMG measures in patients
treated with eculizumab compared with placebo. The magnitude of
effect on QMG observed in this large, prospective registration
trial is unprecedented in more than 30 years of clinical
investigation of refractory MG patients. There is an urgent need in
the MG community for a therapy with the potential to dramatically
improve the lives of patients with refractory gMG, who continue to
experience profound complement-mediated muscle weakness that makes
it difficult or impossible to perform simple daily activities,
including walking, talking, swallowing, and even breathing
normally.
[0527] Pre-specified sensitivity analyses were prospectively
defined to validate results for the primary and first secondary
endpoints. Three of the four prospectively defined MG-ADL
sensitivity analyses achieved p-values <0.05, including the
sensitivity analysis around the primary endpoint for change from
baseline in MG-ADL using repeated measures, which showed a mean
change with eculizumab treatment at week 26 of -4.2 versus a mean
change with placebo at week 26 of -2.3 and achieved a p-value of
0.0058. Additionally, all four prospectively defined QMG
sensitivity analyses achieved p-values <0.05, including the
sensitivity analysis around the first secondary endpoint for change
from baseline in QMG using repeated measures, which showed a mean
change with eculizumab treatment at week 26 of -4.6 versus a mean
change with placebo at week 26 of -1.6 and achieved a p-value of
0.0006.
[0528] The findings from this study underscore the pivotal role of
complement inhibition in addressing the underlying pathophysiology
of refractory gMG. Importantly, the totality of data including the
first three secondary endpoints and a series of prospectively
defined sensitivity analyses, shows early and sustained substantial
improvements over 26 weeks for patients treated with eculizumab
compared to placebo
Example 4
Anti-C5 Antibodies for Use in Treating Refractory Myasthenia
Gravis
[0529] Table 27 below contains sequences of anti-complement protein
C5 specific humanized antibodies that can be used in treating
refractory MG. The antibody was an anti-C5 antibody such as
eculizumab having three heavy chain complementarity determining
regions (CDRs) as set forth in Table 27 using the Kabat definitions
of CDRs as heavy chain CDR1 in SEQ ID NO: 1, heavy chain CDR2 in
SEQ ID NO: 2, and heavy chain CDR3 in SEQ ID NO: 3. The eculizumab
light chain CDRs are set forth below as as light chain CDR1 in SEQ
ID NO: 4, light chain CDR2 in SEQ ID NO: 5 and light chain CDR3 in
SEQ ID NO: 6. The heavy chain variable region of eculizumab is set
forth in SEQ ID NO: 7 and the light chain variable region of
eculizumab is set forth in SEQ ID NO: 8. The complete heavy chain
of eculizumab is set forth below as SEQ ID NO: 10 and the light
chain is set forth below as SEQ ID NO: 11
[0530] The antibody may be an eculizumab variant known as BNJ441
and having selected mutations in the CDR regions combined with
mutations in the Fc region to increase the T1/2 of the antibody in
the patient. The BNJ441 antibody has heavy chain variable region as
set forth in SEQ ID NO: 12 and the light chain variable region of
BNJ441 is set forth in SEQ ID NO: 8. The complete heavy chain of
BNJ441 is set forth below as SEQ ID NO: 14 and the light chain is
set forth below as SEQ ID NO: 11
[0531] The antibody may be an anti-C5 antibody unrelated to
eculizumab such as the 7086 antibody and having three heavy chain
complementarity determining regions (CDRs) as set forth in Table
Table 27 using the Kabat definitions of CDRs as heavy chain CDR1 in
SEQ ID NO: 21, heavy chain CDR2 in SEQ ID NO: 22, and heavy chain
CDR3 in SEQ ID NO: 23. The 7086 antibody light chain CDRs are set
forth below as light chain CDR1 in SEQ ID NO: 24, light chain CDR2
in SEQ ID NO: 25 and light chain CDR3 in SEQ ID NO: 26. The heavy
chain variable region of 7086 is set forth in SEQ ID NO: 27 and the
light chain variable region of 7086 is set forth in SEQ ID NO:
28.
[0532] The antibody may be an anti-C5 antibody unrelated to
eculizumab such as the 8110 antibody and having three heavy chain
complementarity determining regions (CDRs) as set forth in Table 27
using the Kabat definitions of CDRs as heavy chain CDR1 in SEQ ID
NO: 29, heavy chain CDR2 in SEQ ID NO: 30, and heavy chain CDR3 in
SEQ ID NO: 31. The 7086 antibody light chain CDRs are set forth
below as light chain CDR1 in SEQ ID NO: 32, light chain CDR2 in SEQ
ID NO: 33 and light chain CDR3 in SEQ ID NO: 34. The heavy chain
variable region of 8110 is set forth in SEQ ID NO: 35 and the light
chain variable region of 8110 is set forth in SEQ ID NO: 36.
[0533] The antibody may be an anti-C5 antibody or antigen binding
fragment thereof comprising a heavy chain variable region amino
acid sequence according to SEQ ID NO: 37 and a light chain variable
region amino acid sequence according to SEQ ID NO: 38.
Example 5
Dual Responder Analyses of Both Muscle Strength and Activities of
Daily Living, Eculizumab Versus Placebo, in Refractory Generalized
Myasthenia Gravis (gMG) Patients: Results from the REGAIN Study
[0534] The objective of the example was to assess the time course
of response in patients who demonstrated a clinically meaningful
response to eculizumab and the proportion of patients who had
clinically meaningful relevant responses on both the MG-ADL and the
QMG. Patients with refractory gMG continued to receive stable doses
of ISTs (including corticosteroids) throughout the study; patients
were randomized to receive blinded eculizumab 900 mg weekly for 4
weeks, 1200 mg on the fifth week, and then 1200 mg every 2 weeks
thereafter (n=62) or blinded placebo (n=63) (FIG. 12).
[0535] The Myasthenia Gravis Activities of Daily Living (MG-ADL) is
a physician-directed, patient-reported measure of symptom severity
related to MG-specific ADLs (Muppidi, Ann. N.Y. Acad. Sci. 1274:
114-19 (2012)), and the Quantitative Myasthenia Gravis (QMG) tool
is a clinician-reported measure of muscle strength (Barohn et al.,
Ann. N.Y Acad. Sci. 841: 769-72 (1998)). Pre-specified responder
analyses included the proportion of patients who responded with
.gtoreq.3-point improvement in MG-ADL total score with no rescue;
and the proportion of patients with .gtoreq.5-point improvement in
QMG total score with no rescue. In an ad hoc dual responder
analysis, response was defined as an improvement of .gtoreq.3
points from baseline in the MG-ADL total score and improvement of
.gtoreq.5 points from baseline in the QMG total score, with no
rescue therapy. In addition to the prespecified responder
thresholds (i.e., .gtoreq.3-point improvement for MG-ADL and
.gtoreq.5-point improvement for QMG), thresholds of .gtoreq.4, 5,
6, 7, and 8 for MG-ADL and .gtoreq.6, 7, 8, 9, and 10 for QMG were
also examined. P values from a Cochran--Mantel--Haenszel (CMH) test
were provided for the more stringent criteria to aid
interpretation.
[0536] More patients receiving eculizumab than those who received
placebo experienced clinically meaningful responses as defined
above, and also clinically meaningful relevant responses based on
the more stringent thresholds for both MG-ADL and QMG total scores
(FIG. 13). MG-ADL responder analyses conducted at each assessment
date over the 26-week study are shown in FIG. 14 (the proportion of
patients with a .gtoreq.3, 5, or 8 point change in the MG-ADL). QMG
responder analyses conducted at each assessment date over the
26-week study are shown in FIG. 15 (the proportion of patients with
a greater than 5, 7, or 10 point change in the QMG). There was a
substantial overlap of patients who achieved a clinically
meaningful response in both the MG-ADL total score and QMG total
score (FIG. 16). For each of the categorical thresholds of
response, a >3-fold increase was seen in the proportion of
improved patients in the eculizumab group compared with those in
the placebo group (FIG. 16). More patients receiving eculizumab
versus placebo achieved clinically meaningful responses at week 26
in both the MG-ADL and QMG scores (week 26: eculizumab 40% vs
placebo 13%; nominal P<0.001) (FIG. 16). The benefit of
eculizumab treatment was apparent within the first 2 weeks (week 2:
eculizumab 19% vs placebo 6% were dual responders; nominal
P=0.0297) and was sustained through week 26 (all P.ltoreq.0.05)
(FIG. 17).
[0537] Three times as many patients with refractory gMG who were
treated with eculizumab experienced clinically meaningful
improvements in both muscle strength and ADLs compared with the
placebo group by week 26. An increased proportion of individual
assessment responders (on both the MG-ADL and the QMG) as well as
dual responders occurred in the eculizumab-treated patient group
compared with the placebo group which was observed early and
generally maintained over the course of the study.
[0538] As shown in FIG. 18, the response rate was substantially
higher in eculizumab-treated patients (40.3%) than in
placebo-treated patients (12.7%), showing a clinically significant
response by both patient- and physician-assessed outcome measures
in patients treated with eculizumab. With increasingly stringent
response criteria, the superiority of response to eculizumab over
placebo becomes more pronounced, with odds ratios exceeding 10.
Example 6
Efficacy of Eculizumab is Maintained Beyond 26 Weeks in Patients
with AChR+ Refractory Generalized Myasthenia Gravis (gMG)
[0539] Patients who completed REGAIN were allowed to continue into
an open-label extension study known as ECU-MG-302. Each patient
enrolled in the extension trial underwent an initial 4-week blinded
induction before receiving open-label eculizumab maintenance
treatment (1200 mg every 2 weeks). MG-ADL, QMG, MGC, and MG-QOL15
scores and safety were assessed.
[0540] In contrast with Study ECU-MG-301, in which patients were
required to maintain stable MG therapy throughout the 26-week study
period, adjustment of background immunosuppressant therapy (IST),
including corticosteroids and acetylcholinesterase inhibitors
(AChI), was permitted in Study ECU-MG-302. Investigators could
change dosing of an existing IST/AChI, discontinue an existing
IST/AChI, or add a new IST/AChI.
[0541] The MG-ADL total score in eculizumab/eculizumab patients
(n=56) was unchanged from open-label baseline through week 52. In
the placebo/eculizumab patients (n=60), rapid improvement in MG-ADL
total score from open-label baseline was demonstrated with a change
from ECU-MG-302 baseline in MG-ADL total score observed as early as
week 1 (-1.6 [-2.28, -0.89]; p<0.0001). The majority of the
overall treatment effect was achieved by week 4 (-2.4[-3.19,
-1.71]; p<0.0001) during the blind induction phase, and was
sustained through week 52 (-2.7 [-3.73, -1.63]; p<0.0001).
Changes in QMG, MGC, and MG-QOL15 total scores followed a pattern
similar to that of the MG-ADL (QMG: -4.6; P<0.0001; MGC: -5.1;
P<0.0001; and MG-QOL15: --5.7; P=0.005 at week 52). Similar
patterns of response were seen on the respiratory, bulbar, limb,
and ocular MG-ADL domains. The safety profile of eculizumab
remained unchanged throughout the open-label extension study and
was consistent with the known profile.
[0542] Overall, 65 (55.6%) patients reported a change in their IST
usage during the study. Greater proportions of patients had dose
reductions or stopped .gtoreq.1 IST than those who had dose
increases or started .gtoreq.1 IST (Table 26). 55 (47.0%) patients
decreased their daily dose of 1 IST and 2 (1.7%) patients decreased
the daily dose of >1 IST; 29 (24.8%) patients increased their
daily dose of 1 IST, and none increased their dose of >1 IST. 19
(16.2%) patients stopped an existing IST; 5 (4.3%) patients started
a new IST. The most common reason for change in IST therapy was
improvement in MG symptoms, with 42 (35.9%) patients reporting
improvement in MG symptoms as the reason for changing IST therapy.
In comparison, 21 (17.9%) patients reported worsening of MG
symptoms as the primary reason for changing IST therapy.
Side-effects/intolerance to an IST was reported as the reason for
change in IST therapy in 13 (11.1%) patients.
TABLE-US-00025 TABLE 26 SUMMARY OF CHANGES IN IMMUNOSUPPRESSANT
THERAPY STATUS-EXTENSION SAFETY SET Placebo/Eculizumab
Eculizumab/Eculizumab All Patients (N = 61) (N = 56) (N = 117)
Change IST Patients, Change IST Patients, Change IST Patients,
Parameter Events, n n (%) Events, n n (%) Events, n n (%) IST
Change Events and Patients 148 36 (59.0) 157 29 (51.8) 305 65
(55.6) with IST Changes Changes Made in IST Status Start of New IST
2 2 (3.3) 5 3 (5.4) 7 5 (4.3) Stop of an Existing IST 9 7 (11.5) 13
12 (21.4) 22 19 (16.2) Increase the Daily dose of one IST 33 16
(26.2) 37 13 (23.2) 70 29 (24.8) Decrease the Daily dose of one IST
102 30 (49.2) 102 25 (44.6) 204 55 (47.0) Increased the Daily dose
of more than 0 0 (0.0) 0 0 (0.0) 0 0 (0.0) one IST Decreased the
Daily dose of more than 2 2 (3.3) 0 0 (0.0) 2 2 (1.7) one IST
Primary reason for change in IST Status MG symptoms improved 88 26
(42.6) 70 16 (28.6) 158 42 (35.9) MG symptoms worsened 22 11 (18.0)
19 10 (17.9) 41 21 (17.9) Side effects-intolerant to existing IST
12 6 (9.8) 15 7 (12.5) 27 13 (11.1) New indication other than MG
for IST 0 0 (0.0) 1 1 (1.8) 1 1 (0.9) usage Other 26 11 (18.0) 51
12 (21.4) 77 23 (19.7) Abbreviations: IST = immunosuppressant
therapy; MG = myasthenia gravis
[0543] Overall, the extension study demonstrated that patients who
received eculizumab in Study ECU-MG-301 sustained their
improvements through 52 weeks of additional eculizumab treatment in
Study ECU-MG-302. For patients who received placebo in Study
ECU-MG-301, an improvement occurred rapidly after starting
eculizumab treatment and was maintained through 52 weeks of Study
ECU-MG-302, similar to the effect observed in eculizumab-treated
patients in Study ECU-MG-301.
TABLE-US-00026 TABLE 27 SEQUENCE SUMMARY SEQ ID NO: 1 GYIFSNYWIQ
SEQ ID NO: 2 EILPGSGSTEYTENFKD SEQ ID NO: 3 YFFGSSPNWYFDV SEQ ID
NO: 4 GASENIYGALN SEQ ID NO: 5 GATNLAD SEQ ID NO: 6 QNVLNTPLT SEQ
ID NO: 7
QVQLVQSGAEVKKPGASVKVSCKASGYIFSNYWIQWVRQAPGQGLEWMGEILPGSGSTEYTENFK
DRVTMTRDTSTSTVYMELSSLRSEDTAVYYCARYFFGSSPNWYFDVWGQGTLVTVSS SEQ ID
NO: 8
DIQMTQSPSSLSASVGDRVTITCGASENIYGALNWYQQKPGKAPKLLIYGATNLADGVPSRFSGS
GSGTDFTLTISSLQPEDFATYYCQNVLNTPLTFGQGTKVEIK SEQ ID NO: 9
ASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL
SSVVTVPSSNFGTQTYTCNVDHKPSNTKVDKTVERKCCVECPPCPAPPVAGPSVFLFPPKPKDTL
MISRTPEVTCVVVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQDWLNG
KEYKCKVSNKGLPSSIEKTISKAKGQPREPQVYTLPPSQEEMTKNQVSLICLVKGFYPSDIAVEW
ESNGQPENNYKTIPPVLDSDGSFFLYSRLIVDKSRWQEGNVFSCSVMHEALHNHYTQKSLSLSLG K
SEQ ID NO: 10
QVQLVQSGAEVKKPGASVKVSCKASGYIFSNYWIQWVRQAPGQGLEWMGEILPGSGSTEYTENFK
DRVTMTRDTSTSTVYMELSSLRSEDTAVYYCARYFFGSSPNWYFDVWGQGTLVTVSSASTKGPSV
FPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPS
SNFGTQTYTCNVDHKPSNTKVDKTVERKCCVECPPCPAPPVAGPSVFLFPPKPKDTLMISRTPEV
TCVVVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQDWLNGKEYKCKVS
NKGLPSSIEKTISKAKGQPREPQVYTLPPSQEEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPEN
NYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGNVFSCSVMHEALHNHYTQKSLSLSLGK SEQ ID
NO: 11
DIQMTQSPSSLSASVGDRVTITCGASENIYGALNWYQQKPGKAPKLLIYGATNLADGVPSRFSGS
GSGTDFTLTISSLQPEDFATYYCQNVLNTPLTFGQGTKVEIKRTVAAPSVFIFPPSDEQLKSGTA
SVVCLLNNFYPREAKVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTLTLSKADYEKHKVYACE
VTHQGLSSPVTKSFNRGEC SEQ ID NO: 12
QVQLVQSGAEVKKPGASVKVSCKASGHIFSNYWIQWVRQAPGQGLEWMGEILPGSGHTEYTENFK
DRVTMTRDTSTSTVYMELSSLRSEDTAVYYCARYFFGSSPNWYFDVWGQGTLVTVSS SEQ ID
NO: 13
ASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL
SSVVTVPSSNFGTQTYTCNVDHKPSNTKVDKTVERKCCVECPPCPAPPVAGPSVFLFPPKPKDTL
MISRTPEVTCVVVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQDWLNG
KEYKCKVSNKGLPSSIEKTISKAKGQPREPQVYTLPPSQEEMTKNQVSLTCLVKGFYPSDIAVEW
ESNGQPENNYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGNVFSCSVLHEALHSHYTQKSLSLSLG K
SEQ ID NO: 14
QVQLVQSGAEVKKPGASVKVSCKASGHIFSNYWIQWVRQAPGQGLEWMGEILPGSGHTEYTENFK
DRVTMTRDTSTSTVYMELSSLRSEDTAVYYCARYFFGSSPNWYFDVWGQGTLVTVSSASTKGPSV
FPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPS
SNFGTQTYTCNVDHKPSNTKVDKTVERKCCVECPPCPAPPVAGPSVFLFPPKPKDTLMISRTPEV
TCVVVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQDWLNGKEYKCKVS
NKGLPSSIEKTISKAKGQPREPQVYTLPPSQEEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPEN
NYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGNVFSCSVLHEALHSHYTQKSLSLSLGK SEQ ID
NO: 15
ASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL
SSVVTVTSSNFGTQTYTCNVDHKPSNTKVDKTVERKCCVECPPCPAPPVAGPSVFLFPPKPKDTL
YITREPEVTCVVVDVSHEDPEVQFNWYVDGMEVHNAKTKPREEQFNSTFRVVSVLTVVHQDWLNG
KEYKCKVSNKGLPAPIEKTISKTKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEW
ESNGQPENNYKTTPPMLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPG K
SEQ ID NO: 16
QVQLVQSGAEVKKPGASVKVSCKASGYIFSNYWIQWVRQAPGQGLEWMGEILPGSGSTEYTENFK
DRVTMTRDTSTSTVYMELSSLRSEDTAVYYCARYFFGSSPNWYFDVWGQGTLVTVSSASTKGPSV
FPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVTS
SNFGTQTYTCNVDHKPSNTKVDKTVERKCCVECPPCPAPPVAGPSVFLFPPKPKDTLYITREPEV
TCVVVDVSHEDPEVQFNWYVDGMEVHNAKTKPREEQFNSTFRVVSVLTVVHQDWLNGKEYKCKVS
NKGLPAPIEKTISKTKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPEN
NYKTTPPMLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK SEQ ID
NO: 17 GASENIYHALN SEQ ID NO: 18 EILPGSGHTEYTENFKD SEQ ID NO: 19
GHIFSNYWIQ SEQ ID NO: 20
QVQLVQSGAEVKKPGASVKVSCKASGHIFSNYWIQWVRQAPGQGLEWMGEILPGSGHTEYTENFK
DRVTMTRDTSTSTVYMELSSLRSEDTAVYYCARYFFGSSPNWYFDVWGQGTLVTVSSASTKGPSV
FPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPS
SNFGTQTYTCNVDHKPSNTKVDKTVERKCCVECPPCPAPPVAGPSVFLFPPKPKDTLMISRTPEV
TCVVVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQDWLNGKEYKCKVS
NKGLPSSIEKTISKAKGQPREPQVYTLPPSQEEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPEN
NYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGNVFSCSVMHEALHNHYTQKSLSLSLGK SEQ ID
NO: 21 SYAIS SEQ ID NO: 22 GIGPFFGTANYAQKFQG SEQ ID NO: 23 DTPYFDY
SEQ ID NO: 24 SGDSIPNYYVY SEQ ID NO: 25 DDSNRPS SEQ ID NO: 26
QSFDSSLNAEV SEQ ID NO: 27
QVQLVQSGAEVKKPGSSVKVSCKASGGTFSSYAISVWRQAPGQGLEWMGGIGPFFGTANYAQKFQ
GRVTITADESTSTAYMELSSLRSEDTAVYYCARDTPYFDYWGQGTLVTVSS SEQ ID NO: 28
DIELTQPPSVSVAPGQTARISCSGDSIPNYYVYWYQQKPGQAPVLVIYDDSNRPSGIPERFSGSN
SGNTATLTISGTQAEDEADYYCQSFDSSLNAEVFGGGTKLTVL SEQ ID NO: 29 NYIS SEQ
ID NO: 30 IIDPDDSYTEYSPSFQG SEQ ID NO: 31 YEYGGFDI SEQ ID NO: 32
SGDNIGNSYVH SEQ ID NO: 33 KDNDRPS SEQ ID NO: 34 GTYDIESYV SEQ ID
NO: 35
EVQLVQSGAEVKKPGESLKISCKGSGYSFTNYISWVRQMPGKGLEWMGIIDPDDSYTEYSPSFQG
QVTISADKSISTAYLQWSSLKASDTAMYYCARYEYGGFDIWGQGTLVTVSS SEQ ID NO: 36
SYELTQPPSVSVAPGQTARISCSGDNIGNSYVHWYQQKPGQAPVLVIYKDNDRPSGIPERFSGSN
SGNTATLTISGTQAEDEADYYCGTYDIESYVFGGGTKLTVL SEQ ID NO: 37
QVQLVESGGGLVQPGRSLRLSCAASGFTVHSSYYMAWVRQAPGKGLEWVGAIFTGSGAEYKAEWA
KGRVTISKDTSKNQVVLTMTNMDPVDTATYYCASDAGYDYPTHAMHYWGQGTLVTVSS SEQ ID
NO: 38
DIQMIQSPSSLSASVGDRVTITCRASQGISSSLAWYQQKPGKAPKLLIYGASETESGVPSRFSGS
GSGTDFTLTISSLQPEDFATYYCQNTKVGSSYGNTFGGGTKVEIK SEQ ID NO: 39
QVQLVESGGGLVQPGRSLRLSCAASGFTVHSSYYMAWVRQAPGKGLEWVGAIFTGSGAEY
KAEWAKGRVTISKDISKNQVVLIMINMDPVDTATYYCASDAGYDYPTHAMHYWGQGTLVT
VSSASTKGPSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVL
QSSGLYSLSSVVTVPSSSLGTQTYICNVNHKPSNTKVDKKVEPKSCDKTHTCPPCPAPEL
RRGPKVFLFPPKPKDILMISRIPEVICVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREE
QYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKGLPSSIEKTISKAKGQPREPQVYTLPPS
REEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDK
SRWQQGNVFSCSVLHEALHAHYTRKELSLSP
REFERENCES CITED
[0544] The following references are hereby incorporated by
reference in their entirety: [0545] (1) Conti-Fine et al.,
"Myasthenia gravis: past, present, and future," J. Clin. Invest.
116(11): 2843-54 (2006). [0546] (2) Howard J. F., "Clinical
Overview of MG," Myasthenia Gravis Foundation of America, Inc.
2006. [0547] (3) Phillips, "The epidemiology of myasthenia gravis,"
Semin. Neurol. 24(1): 17-20 (2004). [0548] (4) Kim et al.,
"Treatment of myasthenia gravis based on its immunopathogenesis,"
J. Clin. Neurol. 7(4): 173-83 (2011). [0549] (5) Vincent et al.,
"Myasthenia gravis," Adv. Neurol. 88: 159-88 (2002). [0550] (6)
Sahashi et al., "Ultrastructural localization of immune complexes
(IgG and C3) at the end-plate in experimental autoimmune myasthenia
gravis. J Neuropathol. Exp. Neurol. 37(2): 212-23 (1978). [0551]
(7) Dalakas, "Intravenous immunoglobulin in autoimmune
neuromuscular diseases," JAMA 291(19): 2367-75 (2004). [0552] (8)
Engel et al., "Immune complexes (IgG and C3) at the motor end-plate
in myasthenia gravis: ultrastructural and light microscopic
localization and electrophysiologic correlations," Mayo Clin. Proc.
52(5): 267-80 (1977). [0553] (9) Nastuk et al., "Changes in serum
complement activity in patients with myasthenia gravis," Proc. Soc.
Exp. Biol. Med. 105: 177-84 (1960). [0554] (10) Peng et al., "Role
of C5 in the development of airway inflammation, airway
hyperresponsiveness, and ongoing airway response," J. Clin. Invest.
115(6): 1590-600 (2005). [0555] (11) Vakeva et al., "Myocardial
infarction and apoptosis after myocardial ischemia and reperfusion:
role of the terminal complement components and inhibition by
anti-C5 therapy," Circulation 97(22): 2259-67 (1998). [0556] (12)
Wang et al., "Complement inhibition with an anti-C5 monoclonal
antibody prevents hyperacute rejection in a xenograft heart
transplantation model," Transplantation 68(11): 1643-51 (1999).
[0557] (13) Howard et al., "A nandomized, double-blind,
placebo-controlled phase II study of eculizumab in patients with
refractory generalized myasthenia gravis," Muscle Nerve 48(1):
76-84 (2013). [0558] (14) Muppidi et al., "MG-ADL: still a relevant
outcome measure," Muscle Nerve 44(5): 727-31 (2011). [0559] (15)
Benatar et al., "Recommendations for myasthenia gravis clinical
trials," Muscle Nerve 45(6): 909-17 (2012). [0560] (16) Bums et
al., "The MG Composite: A valid and reliable outcome measure for
myasthenia gravis," Neurology 74(18): 1434-40 (2010). [0561] (17)
Bums et al., "The MG-QOL15 for following the health-related quality
of life of patients with myasthenia gravis," Muscle Nerve 43(1):
14-8 (2011). [0562] (18) Cella D., Measuring Quality of Life in
Neurological Disorders; Final Report of the Neuro-QOL Study
September 2010. 2010. [0563] (19) Szende A. and Williams A.,
"Measuring Self-Reported Population Health: An International
Perspective based on EQ-5D, (2004) [0564]
<http://www.euroqol.org/fileadmin/user
upload/Documenten/PDF/Books/Measuring_Self-Reported_Population_Health_-_A-
n_International_Perspective_based_on_EQ-5D.pdf>. [0565] (20)
Posner et al., "The Columbia-Suicide Severity Rating Scale: initial
validity and internal consistency findings from three multisite
studies with adolescents and adults," Am. J. Psychiatry 168(12):
1266-77 (2011). [0566] (21) Nilsson et al., "Columbia--Suicide
Severity Rating Scale Scoring and Data Analysis Guide, (2013)
<http://cssrs.columbia.edu/wp-content/uploads/ScoringandDataAnalysisGu-
ide-for-Clinical-Trials. pdf>.
Sequence CWU 1
1
39110PRTArtificial SequenceHeavy Chain Complementarity Determining
Sequence 1 1Gly Tyr Ile Phe Ser Asn Tyr Trp Ile Gln 1 5 10
217PRTArtificial SequenceHeavy Chain Complementarity Determining
Sequence two 2Glu Ile Leu Pro Gly Ser Gly Ser Thr Glu Tyr Thr Glu
Asn Phe Lys 1 5 10 15 Asp 313PRTArtificial SequenceHeavy Chain
Complementarity Determining Sequence 3 3Tyr Phe Phe Gly Ser Ser Pro
Asn Trp Tyr Phe Asp Val 1 5 10 411PRTArtificial SequenceLight Chain
Complementarity Determining Sequence 1 4Gly Ala Ser Glu Asn Ile Tyr
Gly Ala Leu Asn 1 5 10 57PRTArtificial SequenceLight Chain
Complementarity Determining Sequence 2 5Gly Ala Thr Asn Leu Ala Asp
1 5 69PRTArtificial SequenceLight Chain Complementarity Determining
Sequence 3 6Gln Asn Val Leu Asn Thr Pro Leu Thr 1 5
7122PRTArtificial SequenceHumanized heavy chain variable region
sequence 7Gln 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 Ile
Phe Ser Asn Tyr 20 25 30 Trp Ile Gln Trp Val Arg Gln Ala Pro Gly
Gln Gly Leu Glu Trp Met 35 40 45 Gly Glu Ile Leu Pro Gly Ser Gly
Ser Thr Glu Tyr Thr Glu Asn Phe 50 55 60 Lys Asp Arg Val Thr Met
Thr Arg Asp Thr Ser Thr Ser Thr Val Tyr 65 70 75 80 Met Glu Leu Ser
Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg
Tyr Phe Phe Gly Ser Ser Pro Asn Trp Tyr Phe Asp Val Trp 100 105 110
Gly Gln Gly Thr Leu Val Thr Val Ser Ser 115 120 8107PRTArtificial
SequenceLight Chain variable region sequence 8Asp 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 Ala Ser Glu Asn Ile Tyr Gly Ala 20 25 30 Leu
Asn Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40
45 Tyr Gly Ala Thr Asn Leu Ala Asp 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 Asn Val Leu
Asn Thr Pro Leu 85 90 95 Thr Phe Gly Gln Gly Thr Lys Val Glu Ile
Lys 100 105 9326PRTArtificial SequenceEngineered Heavy Chain
Constant Region IgG2/4 9Ala Ser Thr Lys Gly Pro Ser Val Phe Pro Leu
Ala Pro Cys Ser Arg 1 5 10 15 Ser Thr Ser Glu Ser Thr Ala Ala Leu
Gly Cys Leu Val Lys Asp Tyr 20 25 30 Phe Pro Glu Pro Val Thr Val
Ser Trp Asn Ser Gly Ala Leu Thr Ser 35 40 45 Gly Val His Thr Phe
Pro Ala Val Leu Gln Ser Ser Gly Leu Tyr Ser 50 55 60 Leu Ser Ser
Val Val Thr Val Pro Ser Ser Asn Phe Gly Thr Gln Thr 65 70 75 80 Tyr
Thr Cys Asn Val Asp His Lys Pro Ser Asn Thr Lys Val Asp Lys 85 90
95 Thr Val Glu Arg Lys Cys Cys Val Glu Cys Pro Pro Cys Pro Ala Pro
100 105 110 Pro Val Ala Gly Pro Ser Val Phe Leu Phe Pro Pro Lys Pro
Lys Asp 115 120 125 Thr Leu Met Ile Ser Arg Thr Pro Glu Val Thr Cys
Val Val Val Asp 130 135 140 Val Ser Gln Glu Asp Pro Glu Val Gln Phe
Asn Trp Tyr Val Asp Gly 145 150 155 160 Val Glu Val His Asn Ala Lys
Thr Lys Pro Arg Glu Glu Gln Phe Asn 165 170 175 Ser Thr Tyr Arg Val
Val Ser Val Leu Thr Val Leu His Gln Asp Trp 180 185 190 Leu Asn Gly
Lys Glu Tyr Lys Cys Lys Val Ser Asn Lys Gly Leu Pro 195 200 205 Ser
Ser Ile Glu Lys Thr Ile Ser Lys Ala Lys Gly Gln Pro Arg Glu 210 215
220 Pro Gln Val Tyr Thr Leu Pro Pro Ser Gln Glu Glu Met Thr Lys Asn
225 230 235 240 Gln Val Ser Leu Thr Cys Leu Val Lys Gly Phe Tyr Pro
Ser Asp Ile 245 250 255 Ala Val Glu Trp Glu Ser Asn Gly Gln Pro Glu
Asn Asn Tyr Lys Thr 260 265 270 Thr Pro Pro Val Leu Asp Ser Asp Gly
Ser Phe Phe Leu Tyr Ser Arg 275 280 285 Leu Thr Val Asp Lys Ser Arg
Trp Gln Glu Gly Asn Val Phe Ser Cys 290 295 300 Ser Val Met His Glu
Ala Leu His Asn His Tyr Thr Gln Lys Ser Leu 305 310 315 320 Ser Leu
Ser Leu Gly Lys 325 10448PRTArtificial SequenceHumanized entire
antibody heavy chain sequence 10Gln 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 Ile Phe Ser Asn Tyr 20 25 30 Trp Ile Gln Trp Val
Arg Gln Ala Pro Gly Gln Gly Leu Glu Trp Met 35 40 45 Gly Glu Ile
Leu Pro Gly Ser Gly Ser Thr Glu Tyr Thr Glu Asn Phe 50 55 60 Lys
Asp Arg Val Thr Met Thr Arg Asp Thr Ser Thr Ser Thr Val Tyr 65 70
75 80 Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr Tyr
Cys 85 90 95 Ala Arg Tyr Phe Phe Gly Ser Ser Pro Asn Trp Tyr Phe
Asp Val Trp 100 105 110 Gly Gln Gly Thr Leu Val Thr Val Ser Ser Ala
Ser Thr Lys Gly Pro 115 120 125 Ser Val Phe Pro Leu Ala Pro Cys Ser
Arg Ser Thr Ser Glu Ser Thr 130 135 140 Ala Ala Leu Gly Cys Leu Val
Lys Asp Tyr Phe Pro Glu Pro Val Thr 145 150 155 160 Val Ser Trp Asn
Ser Gly Ala Leu Thr Ser Gly Val His Thr Phe Pro 165 170 175 Ala Val
Leu Gln Ser Ser Gly Leu Tyr Ser Leu Ser Ser Val Val Thr 180 185 190
Val Pro Ser Ser Asn Phe Gly Thr Gln Thr Tyr Thr Cys Asn Val Asp 195
200 205 His Lys Pro Ser Asn Thr Lys Val Asp Lys Thr Val Glu Arg Lys
Cys 210 215 220 Cys Val Glu Cys Pro Pro Cys Pro Ala Pro Pro Val Ala
Gly Pro Ser 225 230 235 240 Val Phe Leu Phe Pro Pro Lys Pro Lys Asp
Thr Leu Met Ile Ser Arg 245 250 255 Thr Pro Glu Val Thr Cys Val Val
Val Asp Val Ser Gln Glu Asp Pro 260 265 270 Glu Val Gln Phe Asn Trp
Tyr Val Asp Gly Val Glu Val His Asn Ala 275 280 285 Lys Thr Lys Pro
Arg Glu Glu Gln Phe Asn Ser Thr Tyr Arg Val Val 290 295 300 Ser Val
Leu Thr Val Leu His Gln Asp Trp Leu Asn Gly Lys Glu Tyr 305 310 315
320 Lys Cys Lys Val Ser Asn Lys Gly Leu Pro Ser Ser Ile Glu Lys Thr
325 330 335 Ile Ser Lys Ala Lys Gly Gln Pro Arg Glu Pro Gln Val Tyr
Thr Leu 340 345 350 Pro Pro Ser Gln Glu Glu Met Thr Lys Asn Gln Val
Ser Leu Thr Cys 355 360 365 Leu Val Lys Gly Phe Tyr Pro Ser Asp Ile
Ala Val Glu Trp Glu Ser 370 375 380 Asn Gly Gln Pro Glu Asn Asn Tyr
Lys Thr Thr Pro Pro Val Leu Asp 385 390 395 400 Ser Asp Gly Ser Phe
Phe Leu Tyr Ser Arg Leu Thr Val Asp Lys Ser 405 410 415 Arg Trp Gln
Glu Gly Asn Val Phe Ser Cys Ser Val Met His Glu Ala 420 425 430 Leu
His Asn His Tyr Thr Gln Lys Ser Leu Ser Leu Ser Leu Gly Lys 435 440
445 11214PRTArtificial SequenceHumanized entire light chain
sequence 11Asp 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 Ala Ser Glu Asn
Ile Tyr Gly Ala 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Lys
Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Gly Ala Thr Asn Leu Ala Asp
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 Asn Val Leu Asn Thr Pro Leu 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 12122PRTArtificial SequenceHumanized and modified heavy
chain variable region sequence 12Gln 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 His Ile Phe Ser Asn Tyr 20 25 30 Trp Ile Gln Trp
Val Arg Gln Ala Pro Gly Gln Gly Leu Glu Trp Met 35 40 45 Gly Glu
Ile Leu Pro Gly Ser Gly His Thr Glu Tyr Thr Glu Asn Phe 50 55 60
Lys Asp Arg Val Thr Met Thr Arg Asp Thr Ser Thr Ser Thr Val Tyr 65
70 75 80 Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr
Tyr Cys 85 90 95 Ala Arg Tyr Phe Phe Gly Ser Ser Pro Asn Trp Tyr
Phe Asp Val Trp 100 105 110 Gly Gln Gly Thr Leu Val Thr Val Ser Ser
115 120 13326PRTArtificial SequenceHumanized and modified heavy
chain constant region sequence 13Ala Ser Thr Lys Gly Pro Ser Val
Phe Pro Leu Ala Pro Cys Ser Arg 1 5 10 15 Ser Thr Ser Glu Ser Thr
Ala Ala Leu Gly Cys Leu Val Lys Asp Tyr 20 25 30 Phe Pro Glu Pro
Val Thr Val Ser Trp Asn Ser Gly Ala Leu Thr Ser 35 40 45 Gly Val
His Thr Phe Pro Ala Val Leu Gln Ser Ser Gly Leu Tyr Ser 50 55 60
Leu Ser Ser Val Val Thr Val Pro Ser Ser Asn Phe Gly Thr Gln Thr 65
70 75 80 Tyr Thr Cys Asn Val Asp His Lys Pro Ser Asn Thr Lys Val
Asp Lys 85 90 95 Thr Val Glu Arg Lys Cys Cys Val Glu Cys Pro Pro
Cys Pro Ala Pro 100 105 110 Pro Val Ala Gly Pro Ser Val Phe Leu Phe
Pro Pro Lys Pro Lys Asp 115 120 125 Thr Leu Met Ile Ser Arg Thr Pro
Glu Val Thr Cys Val Val Val Asp 130 135 140 Val Ser Gln Glu Asp Pro
Glu Val Gln Phe Asn Trp Tyr Val Asp Gly 145 150 155 160 Val Glu Val
His Asn Ala Lys Thr Lys Pro Arg Glu Glu Gln Phe Asn 165 170 175 Ser
Thr Tyr Arg Val Val Ser Val Leu Thr Val Leu His Gln Asp Trp 180 185
190 Leu Asn Gly Lys Glu Tyr Lys Cys Lys Val Ser Asn Lys Gly Leu Pro
195 200 205 Ser Ser Ile Glu Lys Thr Ile Ser Lys Ala Lys Gly Gln Pro
Arg Glu 210 215 220 Pro Gln Val Tyr Thr Leu Pro Pro Ser Gln Glu Glu
Met Thr Lys Asn 225 230 235 240 Gln Val Ser Leu Thr Cys Leu Val Lys
Gly Phe Tyr Pro Ser Asp Ile 245 250 255 Ala Val Glu Trp Glu Ser Asn
Gly Gln Pro Glu Asn Asn Tyr Lys Thr 260 265 270 Thr Pro Pro Val Leu
Asp Ser Asp Gly Ser Phe Phe Leu Tyr Ser Arg 275 280 285 Leu Thr Val
Asp Lys Ser Arg Trp Gln Glu Gly Asn Val Phe Ser Cys 290 295 300 Ser
Val Leu His Glu Ala Leu His Ser His Tyr Thr Gln Lys Ser Leu 305 310
315 320 Ser Leu Ser Leu Gly Lys 325 14448PRTArtificial
SequenceEntire humanized and modified antibody heavy chain sequence
14Gln 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 His Ile Phe Ser Asn
Tyr 20 25 30 Trp Ile Gln Trp Val Arg Gln Ala Pro Gly Gln Gly Leu
Glu Trp Met 35 40 45 Gly Glu Ile Leu Pro Gly Ser Gly His Thr Glu
Tyr Thr Glu Asn Phe 50 55 60 Lys Asp Arg Val Thr Met Thr Arg Asp
Thr Ser Thr Ser Thr Val Tyr 65 70 75 80 Met Glu Leu Ser Ser Leu Arg
Ser Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Tyr Phe Phe
Gly Ser Ser Pro Asn Trp Tyr Phe Asp Val Trp 100 105 110 Gly Gln Gly
Thr Leu Val Thr Val Ser Ser Ala Ser Thr Lys Gly Pro 115 120 125 Ser
Val Phe Pro Leu Ala Pro Cys Ser Arg Ser Thr Ser Glu Ser Thr 130 135
140 Ala Ala Leu Gly Cys Leu Val Lys Asp Tyr Phe Pro Glu Pro Val Thr
145 150 155 160 Val Ser Trp Asn Ser Gly Ala Leu Thr Ser Gly Val His
Thr Phe Pro 165 170 175 Ala Val Leu Gln Ser Ser Gly Leu Tyr Ser Leu
Ser Ser Val Val Thr 180 185 190 Val Pro Ser Ser Asn Phe Gly Thr Gln
Thr Tyr Thr Cys Asn Val Asp 195 200 205 His Lys Pro Ser Asn Thr Lys
Val Asp Lys Thr Val Glu Arg Lys Cys 210 215 220 Cys Val Glu Cys Pro
Pro Cys Pro Ala Pro Pro Val Ala Gly Pro Ser 225 230 235 240 Val Phe
Leu Phe Pro Pro Lys Pro Lys Asp Thr Leu Met Ile Ser Arg 245 250 255
Thr Pro Glu Val Thr Cys Val Val Val Asp Val Ser Gln Glu Asp Pro 260
265 270 Glu Val Gln Phe Asn Trp Tyr Val Asp Gly Val Glu Val His Asn
Ala 275 280 285 Lys Thr Lys Pro Arg Glu Glu Gln Phe Asn Ser Thr Tyr
Arg Val Val 290 295 300 Ser Val Leu Thr Val Leu His Gln Asp Trp Leu
Asn Gly Lys Glu Tyr 305 310 315 320 Lys Cys Lys Val Ser Asn Lys Gly
Leu Pro Ser Ser Ile Glu Lys Thr 325 330 335 Ile Ser Lys Ala Lys Gly
Gln Pro Arg Glu Pro Gln Val Tyr Thr Leu 340 345 350 Pro Pro Ser Gln
Glu Glu Met Thr Lys Asn Gln Val Ser Leu Thr Cys 355 360 365 Leu Val
Lys Gly Phe Tyr Pro Ser Asp Ile Ala Val Glu Trp Glu Ser 370 375 380
Asn Gly Gln Pro Glu Asn Asn Tyr Lys Thr Thr Pro Pro Val Leu Asp 385
390 395 400 Ser Asp Gly Ser Phe Phe Leu Tyr Ser Arg Leu Thr Val Asp
Lys Ser 405 410 415 Arg Trp Gln Glu Gly Asn Val Phe Ser Cys Ser Val
Leu His Glu
Ala 420 425 430 Leu His Ser His Tyr Thr Gln Lys Ser Leu Ser Leu Ser
Leu Gly Lys 435 440 445 15326PRTArtificial SequenceHeavy chain
constant region modified IgG2/4 15Ala Ser Thr Lys Gly Pro Ser Val
Phe Pro Leu Ala Pro Cys Ser Arg 1 5 10 15 Ser Thr Ser Glu Ser Thr
Ala Ala Leu Gly Cys Leu Val Lys Asp Tyr 20 25 30 Phe Pro Glu Pro
Val Thr Val Ser Trp Asn Ser Gly Ala Leu Thr Ser 35 40 45 Gly Val
His Thr Phe Pro Ala Val Leu Gln Ser Ser Gly Leu Tyr Ser 50 55 60
Leu Ser Ser Val Val Thr Val Thr Ser Ser Asn Phe Gly Thr Gln Thr 65
70 75 80 Tyr Thr Cys Asn Val Asp His Lys Pro Ser Asn Thr Lys Val
Asp Lys 85 90 95 Thr Val Glu Arg Lys Cys Cys Val Glu Cys Pro Pro
Cys Pro Ala Pro 100 105 110 Pro Val Ala Gly Pro Ser Val Phe Leu Phe
Pro Pro Lys Pro Lys Asp 115 120 125 Thr Leu Tyr Ile Thr Arg Glu Pro
Glu Val Thr Cys Val Val Val Asp 130 135 140 Val Ser His Glu Asp Pro
Glu Val Gln Phe Asn Trp Tyr Val Asp Gly 145 150 155 160 Met Glu Val
His Asn Ala Lys Thr Lys Pro Arg Glu Glu Gln Phe Asn 165 170 175 Ser
Thr Phe Arg Val Val Ser Val Leu Thr Val Val His Gln Asp Trp 180 185
190 Leu Asn Gly Lys Glu Tyr Lys Cys Lys Val Ser Asn Lys Gly Leu Pro
195 200 205 Ala Pro Ile Glu Lys Thr Ile Ser Lys Thr Lys Gly Gln Pro
Arg Glu 210 215 220 Pro Gln Val Tyr Thr Leu Pro Pro Ser Arg Glu Glu
Met Thr Lys Asn 225 230 235 240 Gln Val Ser Leu Thr Cys Leu Val Lys
Gly Phe Tyr Pro Ser Asp Ile 245 250 255 Ala Val Glu Trp Glu Ser Asn
Gly Gln Pro Glu Asn Asn Tyr Lys Thr 260 265 270 Thr Pro Pro Met Leu
Asp Ser Asp Gly Ser Phe Phe Leu Tyr Ser Lys 275 280 285 Leu Thr Val
Asp Lys Ser Arg Trp Gln Gln Gly Asn Val Phe Ser Cys 290 295 300 Ser
Val Met His Glu Ala Leu His Asn His Tyr Thr Gln Lys Ser Leu 305 310
315 320 Ser Leu Ser Pro Gly Lys 325 16448PRTArtificial
SequenceModified and humanized entire antibody heavy chain 16Gln
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 Ile Phe Ser Asn Tyr
20 25 30 Trp Ile Gln Trp Val Arg Gln Ala Pro Gly Gln Gly Leu Glu
Trp Met 35 40 45 Gly Glu Ile Leu Pro Gly Ser Gly Ser Thr Glu Tyr
Thr Glu Asn Phe 50 55 60 Lys Asp Arg Val Thr Met Thr Arg Asp Thr
Ser Thr Ser Thr Val Tyr 65 70 75 80 Met Glu Leu Ser Ser Leu Arg Ser
Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Tyr Phe Phe Gly
Ser Ser Pro Asn Trp Tyr Phe Asp Val Trp 100 105 110 Gly Gln Gly Thr
Leu Val Thr Val Ser Ser Ala Ser Thr Lys Gly Pro 115 120 125 Ser Val
Phe Pro Leu Ala Pro Cys Ser Arg Ser Thr Ser Glu Ser Thr 130 135 140
Ala Ala Leu Gly Cys Leu Val Lys Asp Tyr Phe Pro Glu Pro Val Thr 145
150 155 160 Val Ser Trp Asn Ser Gly Ala Leu Thr Ser Gly Val His Thr
Phe Pro 165 170 175 Ala Val Leu Gln Ser Ser Gly Leu Tyr Ser Leu Ser
Ser Val Val Thr 180 185 190 Val Thr Ser Ser Asn Phe Gly Thr Gln Thr
Tyr Thr Cys Asn Val Asp 195 200 205 His Lys Pro Ser Asn Thr Lys Val
Asp Lys Thr Val Glu Arg Lys Cys 210 215 220 Cys Val Glu Cys Pro Pro
Cys Pro Ala Pro Pro Val Ala Gly Pro Ser 225 230 235 240 Val Phe Leu
Phe Pro Pro Lys Pro Lys Asp Thr Leu Tyr Ile Thr Arg 245 250 255 Glu
Pro Glu Val Thr Cys Val Val Val Asp Val Ser His Glu Asp Pro 260 265
270 Glu Val Gln Phe Asn Trp Tyr Val Asp Gly Met Glu Val His Asn Ala
275 280 285 Lys Thr Lys Pro Arg Glu Glu Gln Phe Asn Ser Thr Phe Arg
Val Val 290 295 300 Ser Val Leu Thr Val Val His Gln Asp Trp Leu Asn
Gly Lys Glu Tyr 305 310 315 320 Lys Cys Lys Val Ser Asn Lys Gly Leu
Pro Ala Pro Ile Glu Lys Thr 325 330 335 Ile Ser Lys Thr Lys Gly Gln
Pro Arg Glu Pro Gln Val Tyr Thr Leu 340 345 350 Pro Pro Ser Arg Glu
Glu Met Thr Lys Asn Gln Val Ser Leu Thr Cys 355 360 365 Leu Val Lys
Gly Phe Tyr Pro Ser Asp Ile Ala Val Glu Trp Glu Ser 370 375 380 Asn
Gly Gln Pro Glu Asn Asn Tyr Lys Thr Thr Pro Pro Met Leu Asp 385 390
395 400 Ser Asp Gly Ser Phe Phe Leu Tyr Ser Lys Leu Thr Val Asp Lys
Ser 405 410 415 Arg Trp Gln Gln Gly Asn Val Phe Ser Cys Ser Val Met
His Glu Ala 420 425 430 Leu His Asn His Tyr Thr Gln Lys Ser Leu Ser
Leu Ser Pro Gly Lys 435 440 445 1711PRTArtificial SequenceModified
CDR sequence 17Gly Ala Ser Glu Asn Ile Tyr His Ala Leu Asn 1 5 10
1817PRTArtificial SequenceModified Heavy Chain CDR 2 sequence 18Glu
Ile Leu Pro Gly Ser Gly His Thr Glu Tyr Thr Glu Asn Phe Lys 1 5 10
15 Asp 1910PRTArtificial SequenceModified heavy chain CDR1 sequence
19Gly His Ile Phe Ser Asn Tyr Trp Ile Gln 1 5 10 20448PRTArtificial
SequenceModified and humanized entire human heavy chain sequence
20Gln 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 His Ile Phe Ser Asn
Tyr 20 25 30 Trp Ile Gln Trp Val Arg Gln Ala Pro Gly Gln Gly Leu
Glu Trp Met 35 40 45 Gly Glu Ile Leu Pro Gly Ser Gly His Thr Glu
Tyr Thr Glu Asn Phe 50 55 60 Lys Asp Arg Val Thr Met Thr Arg Asp
Thr Ser Thr Ser Thr Val Tyr 65 70 75 80 Met Glu Leu Ser Ser Leu Arg
Ser Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Tyr Phe Phe
Gly Ser Ser Pro Asn Trp Tyr Phe Asp Val Trp 100 105 110 Gly Gln Gly
Thr Leu Val Thr Val Ser Ser Ala Ser Thr Lys Gly Pro 115 120 125 Ser
Val Phe Pro Leu Ala Pro Cys Ser Arg Ser Thr Ser Glu Ser Thr 130 135
140 Ala Ala Leu Gly Cys Leu Val Lys Asp Tyr Phe Pro Glu Pro Val Thr
145 150 155 160 Val Ser Trp Asn Ser Gly Ala Leu Thr Ser Gly Val His
Thr Phe Pro 165 170 175 Ala Val Leu Gln Ser Ser Gly Leu Tyr Ser Leu
Ser Ser Val Val Thr 180 185 190 Val Pro Ser Ser Asn Phe Gly Thr Gln
Thr Tyr Thr Cys Asn Val Asp 195 200 205 His Lys Pro Ser Asn Thr Lys
Val Asp Lys Thr Val Glu Arg Lys Cys 210 215 220 Cys Val Glu Cys Pro
Pro Cys Pro Ala Pro Pro Val Ala Gly Pro Ser 225 230 235 240 Val Phe
Leu Phe Pro Pro Lys Pro Lys Asp Thr Leu Met Ile Ser Arg 245 250 255
Thr Pro Glu Val Thr Cys Val Val Val Asp Val Ser Gln Glu Asp Pro 260
265 270 Glu Val Gln Phe Asn Trp Tyr Val Asp Gly Val Glu Val His Asn
Ala 275 280 285 Lys Thr Lys Pro Arg Glu Glu Gln Phe Asn Ser Thr Tyr
Arg Val Val 290 295 300 Ser Val Leu Thr Val Leu His Gln Asp Trp Leu
Asn Gly Lys Glu Tyr 305 310 315 320 Lys Cys Lys Val Ser Asn Lys Gly
Leu Pro Ser Ser Ile Glu Lys Thr 325 330 335 Ile Ser Lys Ala Lys Gly
Gln Pro Arg Glu Pro Gln Val Tyr Thr Leu 340 345 350 Pro Pro Ser Gln
Glu Glu Met Thr Lys Asn Gln Val Ser Leu Thr Cys 355 360 365 Leu Val
Lys Gly Phe Tyr Pro Ser Asp Ile Ala Val Glu Trp Glu Ser 370 375 380
Asn Gly Gln Pro Glu Asn Asn Tyr Lys Thr Thr Pro Pro Val Leu Asp 385
390 395 400 Ser Asp Gly Ser Phe Phe Leu Tyr Ser Arg Leu Thr Val Asp
Lys Ser 405 410 415 Arg Trp Gln Glu Gly Asn Val Phe Ser Cys Ser Val
Met His Glu Ala 420 425 430 Leu His Asn His Tyr Thr Gln Lys Ser Leu
Ser Leu Ser Leu Gly Lys 435 440 445 215PRTArtificial SequenceHeavy
chain CDR1 sequence 21Ser Tyr Ala Ile Ser 1 5 2217PRTArtificial
SequenceHeavy chain CDR2 sequence 22Gly Ile Gly Pro Phe Phe Gly Thr
Ala Asn Tyr Ala Gln Lys Phe Gln 1 5 10 15 Gly 237PRTArtificial
Sequenceheavy chain CDR3 sequence 23Asp Thr Pro Tyr Phe Asp Tyr 1 5
2411PRTArtificial SequenceLight Chain CDR1 sequence 24Ser Gly Asp
Ser Ile Pro Asn Tyr Tyr Val Tyr 1 5 10 257PRTArtificial
SequenceLight chain CDR2 sequence 25Asp Asp Ser Asn Arg Pro Ser 1 5
2611PRTArtificial SequenceLight chain CDR3 sequence 26Gln Ser Phe
Asp Ser Ser Leu Asn Ala Glu Val 1 5 10 27116PRTArtificial
SequenceHeavy chain variable region sequence 27Gln Val Gln Leu Val
Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Ser 1 5 10 15 Ser Val Lys
Val Ser Cys Lys Ala Ser Gly Gly Thr Phe Ser Ser Tyr 20 25 30 Ala
Ile Ser Val Trp Arg Gln Ala Pro Gly Gln Gly Leu Glu Trp Met 35 40
45 Gly Gly Ile Gly Pro Phe Phe Gly Thr Ala Asn Tyr Ala Gln Lys Phe
50 55 60 Gln Gly Arg Val Thr Ile Thr Ala Asp Glu Ser Thr Ser Thr
Ala Tyr 65 70 75 80 Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala
Val Tyr Tyr Cys 85 90 95 Ala Arg Asp Thr Pro Tyr Phe Asp Tyr Trp
Gly Gln Gly Thr Leu Val 100 105 110 Thr Val Ser Ser 115
28108PRTArtificial SequenceLight chain variable region sequence
28Asp Ile Glu Leu Thr Gln Pro Pro Ser Val Ser Val Ala Pro Gly Gln 1
5 10 15 Thr Ala Arg Ile Ser Cys Ser Gly Asp Ser Ile Pro Asn Tyr Tyr
Val 20 25 30 Tyr Trp Tyr Gln Gln Lys Pro Gly Gln Ala Pro Val Leu
Val Ile Tyr 35 40 45 Asp Asp Ser Asn Arg Pro Ser Gly Ile Pro Glu
Arg Phe Ser Gly Ser 50 55 60 Asn Ser Gly Asn Thr Ala Thr Leu Thr
Ile Ser Gly Thr Gln Ala Glu 65 70 75 80 Asp Glu Ala Asp Tyr Tyr Cys
Gln Ser Phe Asp Ser Ser Leu Asn Ala 85 90 95 Glu Val Phe Gly Gly
Gly Thr Lys Leu Thr Val Leu 100 105 294PRTArtificial SequenceHeavy
chain CDR1 sequence 29Asn Tyr Ile Ser 1 3017PRTArtificial
SequenceHeavy chain CDR2 sequence 30Ile Ile Asp Pro Asp Asp Ser Tyr
Thr Glu Tyr Ser Pro Ser Phe Gln 1 5 10 15 Gly 318PRTArtificial
SequenceHeavy chain CDR3 sequence 31Tyr Glu Tyr Gly Gly Phe Asp Ile
1 5 3211PRTArtificial SequenceLight chain CDR1 sequence 32Ser Gly
Asp Asn Ile Gly Asn Ser Tyr Val His 1 5 10 337PRTArtificial
SequenceLight chain CDR2 sequence 33Lys Asp Asn Asp Arg Pro Ser 1 5
349PRTArtificial SequenceLight chain CDR3 sequence 34Gly Thr Tyr
Asp Ile Glu Ser Tyr Val 1 5 35116PRTArtificial SequenceHeavy chain
variable region sequence 35Glu Val Gln Leu Val Gln Ser Gly Ala Glu
Val Lys Lys Pro Gly Glu 1 5 10 15 Ser Leu Lys Ile Ser Cys Lys Gly
Ser Gly Tyr Ser Phe Thr Asn Tyr 20 25 30 Ile Ser Trp Val Arg Gln
Met Pro Gly Lys Gly Leu Glu Trp Met Gly 35 40 45 Ile Ile Asp Pro
Asp Asp Ser Tyr Thr Glu Tyr Ser Pro Ser Phe Gln 50 55 60 Gly Gln
Val Thr Ile Ser Ala Asp Lys Ser Ile Ser Thr Ala Tyr Leu 65 70 75 80
Gln Trp Ser Ser Leu Lys Ala Ser Asp Thr Ala Met Tyr Tyr Cys Ala 85
90 95 Arg Tyr Glu Tyr Gly Gly Phe Asp Ile Trp Gly Gln Gly Thr Leu
Val 100 105 110 Thr Val Ser Ser 115 36106PRTArtificial
SequenceLight chain variable region sequence 36Ser Tyr Glu Leu Thr
Gln Pro Pro Ser Val Ser Val Ala Pro Gly Gln 1 5 10 15 Thr Ala Arg
Ile Ser Cys Ser Gly Asp Asn Ile Gly Asn Ser Tyr Val 20 25 30 His
Trp Tyr Gln Gln Lys Pro Gly Gln Ala Pro Val Leu Val Ile Tyr 35 40
45 Lys Asp Asn Asp Arg Pro Ser Gly Ile Pro Glu Arg Phe Ser Gly Ser
50 55 60 Asn Ser Gly Asn Thr Ala Thr Leu Thr Ile Ser Gly Thr Gln
Ala Glu 65 70 75 80 Asp Glu Ala Asp Tyr Tyr Cys Gly Thr Tyr Asp Ile
Glu Ser Tyr Val 85 90 95 Phe Gly Gly Gly Thr Lys Leu Thr Val Leu
100 105 37123PRTArtificial SequenceVariable heavy chain 37Gln Val
Gln Leu Val Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Arg 1 5 10 15
Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Val His Ser Ser 20
25 30 Tyr Tyr Met Ala Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu
Trp 35 40 45 Val Gly Ala Ile Phe Thr Gly Ser Gly Ala Glu Tyr Lys
Ala Glu Trp 50 55 60 Ala Lys Gly Arg Val Thr Ile Ser Lys Asp Thr
Ser Lys Asn Gln Val 65 70 75 80 Val Leu Thr Met Thr Asn Met Asp Pro
Val Asp Thr Ala Thr Tyr Tyr 85 90 95 Cys Ala Ser Asp Ala Gly Tyr
Asp Tyr Pro Thr His Ala Met His Tyr 100 105 110 Trp Gly Gln Gly Thr
Leu Val Thr Val Ser Ser 115 120 38110PRTArtificial SequenceVariable
light chain 38Asp 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 Arg Ala Ser Gln
Gly Ile Ser Ser Ser 20 25 30 Leu Ala Trp Tyr Gln Gln Lys Pro Gly
Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Gly Ala Ser Glu Thr Glu
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 Asn Thr Lys Val Gly Ser Ser 85 90 95 Tyr
Gly Asn Thr Phe Gly Gly Gly Thr Lys Val Glu Ile Lys 100 105 110
39451PRTArtificial SequenceHeavy chain 39Gln Val Gln Leu Val Glu
Ser Gly Gly Gly Leu Val Gln Pro Gly Arg 1 5 10 15 Ser Leu Arg Leu
Ser Cys Ala Ala Ser Gly Phe Thr Val His Ser Ser 20 25 30 Tyr Tyr
Met Ala Trp Val Arg Gln Ala
Pro Gly Lys Gly Leu Glu Trp 35 40 45 Val Gly Ala Ile Phe Thr Gly
Ser Gly Ala Glu Tyr Lys Ala Glu Trp 50 55 60 Ala Lys Gly Arg Val
Thr Ile Ser Lys Asp Thr Ser Lys Asn Gln Val 65 70 75 80 Val Leu Thr
Met Thr Asn Met Asp Pro Val Asp Thr Ala Thr Tyr Tyr 85 90 95 Cys
Ala Ser Asp Ala Gly Tyr Asp Tyr Pro Thr His Ala Met His Tyr 100 105
110 Trp Gly Gln Gly Thr Leu Val Thr Val Ser Ser Ala Ser Thr Lys Gly
115 120 125 Pro Ser Val Phe Pro Leu Ala Pro Ser Ser Lys Ser Thr Ser
Gly Gly 130 135 140 Thr Ala Ala Leu Gly Cys Leu Val Lys Asp Tyr Phe
Pro Glu Pro Val 145 150 155 160 Thr Val Ser Trp Asn Ser Gly Ala Leu
Thr Ser Gly Val His Thr Phe 165 170 175 Pro Ala Val Leu Gln Ser Ser
Gly Leu Tyr Ser Leu Ser Ser Val Val 180 185 190 Thr Val Pro Ser Ser
Ser Leu Gly Thr Gln Thr Tyr Ile Cys Asn Val 195 200 205 Asn His Lys
Pro Ser Asn Thr Lys Val Asp Lys Lys Val Glu Pro Lys 210 215 220 Ser
Cys Asp Lys Thr His Thr Cys Pro Pro Cys Pro Ala Pro Glu Leu 225 230
235 240 Arg Arg Gly Pro Lys Val Phe Leu Phe Pro Pro Lys Pro Lys Asp
Thr 245 250 255 Leu Met Ile Ser Arg Thr Pro Glu Val Thr Cys Val Val
Val Asp Val 260 265 270 Ser His Glu Asp Pro Glu Val Lys Phe Asn Trp
Tyr Val Asp Gly Val 275 280 285 Glu Val His Asn Ala Lys Thr Lys Pro
Arg Glu Glu Gln Tyr Asn Ser 290 295 300 Thr Tyr Arg Val Val Ser Val
Leu Thr Val Leu His Gln Asp Trp Leu 305 310 315 320 Asn Gly Lys Glu
Tyr Lys Cys Lys Val Ser Asn Lys Gly Leu Pro Ser 325 330 335 Ser Ile
Glu Lys Thr Ile Ser Lys Ala Lys Gly Gln Pro Arg Glu Pro 340 345 350
Gln Val Tyr Thr Leu Pro Pro Ser Arg Glu Glu Met Thr Lys Asn Gln 355
360 365 Val Ser Leu Thr Cys Leu Val Lys Gly Phe Tyr Pro Ser Asp Ile
Ala 370 375 380 Val Glu Trp Glu Ser Asn Gly Gln Pro Glu Asn Asn Tyr
Lys Thr Thr 385 390 395 400 Pro Pro Val Leu Asp Ser Asp Gly Ser Phe
Phe Leu Tyr Ser Lys Leu 405 410 415 Thr Val Asp Lys Ser Arg Trp Gln
Gln Gly Asn Val Phe Ser Cys Ser 420 425 430 Val Leu His Glu Ala Leu
His Ala His Tyr Thr Arg Lys Glu Leu Ser 435 440 445 Leu Ser Pro
450
* * * * *
References