Patent Application
20190307860
The invention concerns methods for the treatment of symptomatic celiac disease, gluten intolerance or gluten sensitivity. The invention specifically concerns reduction of the severity and/or frequency of symptoms associated with or clinical manifestations of symptomatic celiac disease, gluten intolerance, or gluten sensitivity.
Celiac disease is an acquired chronic immune disorder that develops in susceptible individuals (many of whom are of HLA genotype DQ2 or DQ8) related to an environmental factor, gluten, which is the storage protein of wheat and related grains like rye and barley [(Fasano and Catassi 2001), (Van Heel and West 2006), (Rostom, Murray et al. 2006), (Green and Cellier 2007); a list of the full citation of references cited herein by author name(s) and year of publication is provided at the end of the detailed description of the invention]. The prevalence of celiac disease in Europe and in the United States has been estimated to be approximately 1-2% of the population [(Mäki, Mustalahti et al. 2003), (Fasano, Berti et al. 2003), (West 2003), (Bingley, Williams et al. 2004), (Shan, Qiao et al. 2005), (Van Heel and West 2006), (Green 2007)]. Celiac disease has a wide range of clinical manifestations including latent or silent celiac disease, disease with only mild gastrointestinal disturbances, chronic gastrointestinal symptoms, malabsorption, and/or weight loss. Celiac disease is often diagnosed in patients with isolated iron deficiency anemia.
The ingestion of gluten-containing cereals can also induce manifestations outside the gut (Maki and Collin 1997), such as osteoporosis, peripheral and central nervous system involvement (Hadjivassiliou 2006), mild or severe liver disease, infertility problems, and the classical example is the gluten-induced skin disease, dermatitis herpetiformis. Dermatitis herpetiformis (DH) is a cutaneous manifestation of celiac disease in which an intensely pruritic, herptiform rash can present on the elbows, knees, buttocks, and scalp of a celiac disease patient in response to ingestion of gluten. The rash is characterized by high IgA deposits seen histologically in the upper papillary dermis. The symptoms and histology of the rash improve with adherence to a gluten free diet. Approximately 10% of patients diagnosed with celiac disease will manifest DH. The gluten-induced small bowel pathology in celiac disease is characterized by an inflammatory reaction that is accompanied by villus atrophy and hypertrophy of crypts (Kagnoff 2007).
The only accepted gold standard for celiac disease diagnosis is the finding of gluten-induced small intestinal mucosal injury [(Walker-Smith 1990), (Rostom, Murray et al. 2006)]. Clinical findings are usually equivocal: newly diagnosed patients eating normal gluten-containing food may be totally symptomless or have only vague gastrointestinal symptoms whereas in others symptoms may be severe; in people with extra-intestinal manifestations gastrointestinal symptoms may also be absent, thus having a clinically silent celiac disease. One feature that is common to all however is the manifest gluten-sensitive small intestinal mucosal lesion. In untreated celiac disease, the length of functionally impaired bowel determines the degree of malabsorption and the presence of symptoms does not relate at all to the histological features of the proximal biopsy [(Macdonald, Brandborg et al. 1964), (Marsh and Crowe 1995)]. This also explains why oral glucose tolerance tests, fecal fat excretion, d-xylose excretion tests, hematologic investigations, and radiologic examination of the small bowel fail to distinguish patients with suspected malabsorption from those with or without mucosal atrophy and, thus, frequently give misleading results (Sanderson 1975). Only patients with extensive and severe enteropathy will have evidence of steatorrhea and increased intestinal permeability; in patients with mild-to-moderate enteropathy these tests may remain normal, and therefore these tests are no longer important tools in cases of suspected celiac disease or while monitoring dietary treatment (Farrell and Kelly 2002). Furthermore, recent guidelines and management models for celiac disease diagnosis and treatment in the USA no longer recommend these functional studies [(Hill I D 2005), (Rostom, Murray et al. 2006)]. Instead, during the last two decades, highly sensitive and specific gluten-dependent serum autoantibody tests have been used for celiac disease case finding, population-based screening studies, monitoring the gluten-free diet, and measurement of mucosal relapse on gluten challenge [(Mäki, Hallstrom et al. 1984), (Mäki, Landeaho et al. 1989), (Mäki 1991), (Mäki 1995), (Dieterich 1998), (Sulkanen, Halttunen et al. 1998), (Mustalahti 2002), (Kaukinen, Halme et al. 2002), (Mäki, Mustalahti et al. 2003), (Korponay-Szabo, Raivio et al. 2005), (Collin 2005), (Hill I D 2005), (Holm, Mäki et al. 2006), (Raivio 2006), (Rostom, Murray et al. 2006), (Kurppa 2009)].
For patients with celiac disease, lifelong complete gluten exclusion needs to be strictly followed to avoid a substantially enhanced risk for the development of further complications, such as bone disorders, infertility, and cancer [(Peters, Askling et al. 2003), (Van Heel and West 2006), (Rostom, Murray et al. 2006), (Green and Cellier 2007)]. The mortality rate in patients with celiac disease exceeds that of the general population; however, there is a trend towards reduction in mortality after 1-5 years on a gluten-free diet [(Corrao, Corazza et al. 2001); Rubio-Tapia, et al. 2010)].
Following a completely gluten-free diet is, however, very challenging. Even highly motivated patients who try to maintain a strict dietary regimen are affected due to inadvertent or background exposure to gluten (FDA 2006). As many as 80% of patients with celiac disease who are in clinical remission and who claim to be following a gluten-free diet, have persistent abnormalities in small bowel biopsy specimens [(Lee and Newman 2003), (Bardella, Velio et al. 2007)]. Inadvertent exposure to gluten has been identified as the leading cause of non-responsive celiac disease among clinically diagnosed patients who were presumed to be on a gluten-free diet (Abdulkarim, Burgart et al. 2002). It is evident that a gluten-free diet is more expensive than a so-called ‘normal’ diet; also social life and travel contribute to dietary lapses. Taken together, there is an acute need for non-dietary therapies for celiac disease (Khosla, Gray et al. 2005).
As reviewed by Marsh and Crowe (Marsh and Crowe 1995), time-course studies of gluten challenges provide clear evidence of an inflammatory process, a dose-dependent accumulation of lymphocytes to the epithelium during the lower-dose challenges. Upon further challenge, crypt hyperplasia occurs and lastly, villus effacement is seen (flat mucosal lesion). As evidenced in clinical practice (silent celiac disease), also upon gluten challenge, the mucosal deterioration is often seen before clinical symptoms occur (Maki, Landeaho et al. 1989). When challenging adolescents and young adults with 10 g of gluten per day, and performing a control small intestinal biopsy at the time of seroconversion of the celiac-type autoantibodies, it became evident that the gut mucosa relapsed in 70% of the patients before clinical symptoms occurred. Thus, gluten-induced damage in the small intestinal mucosa is a prerequisite for symptoms and complications of celiac disease, some of which may occur only years or decades after starting gluten ingestion.
Diagnosed celiac disease patients in Finland have typically had at least two upper gastrointestinal endoscopies with multiple biopsies, first at the initial diagnosis and the other approximately one year later to show gut mucosal healing upon a gluten-free diet (Management Model of Celiac Disease in Finland). The Celiac Disease Study Group in Tampere, Finland, has used small intestinal mucosal morphometric analyses to determine ingested wheat-, rye-, and barley- (gluten)-induced mucosal inflammation and mucosal architectural changes in early developing celiac disease, in active and clinically silent disease, during treatment follow-up of patients when the mucosa is healing [(Mäki 1991), (Holm, Mäki et al. 1992), (Holm 1993), (Iltanen, Holm et al. 1999) (Kaukinen, Collin et al. 1998), (Kaukinen, Collin et al. 1999), (Kaukinen 2000), (Kaukinen 2001), (Jarvinen, Kaukinen et al. 2003), (Peraaho, Kaukinen et al. 2003), (Jarvinen 2004), (Collin, Thorell et al. 2004), (Kaukinen 2005), (Salmi 2006)], as well as during gluten challenge (Holm, Mäki et al. 2006). These parameters have included determination of the villus height/crypt depth ratio to establish manifest gluten-induced mucosal architectural change, and counting of the intraepithelial densities of all T lymphocytes (CD3-positive IELs), and densities of αβ+ and γδ+ T cell receptor-bearing IELs to reveal gluten-induced inflammatory changes.
People eating an average Western diet ingest approximately 15-25 g gluten per day. In celiac disease, the onset of symptoms and signs of gluten intolerance may occur in childhood but become evident most often only in adulthood or in the elderly after decades of gluten ingestion. It has been shown in previous clinical gluten challenge studies that older children, adolescents and young adults with long-term treated celiac disease can tolerate well the ingestion of 10-20 g gluten per day [(Mäki, Landeaho et al. 1989), (Holm, Mäki et al. 2006)]. Also, a gluten challenge with repeated small intestinal mucosal biopsies has until fairly recently been mandatory to establish the definite diagnosis of celiac disease, especially in children (in some parts of the world this regimen is still followed). The effect of small gluten loads on the mucosal integrity and a safe gluten threshold in treated celiac disease is still under discussion [(Peraaho, Kaukinen et al. 2003), (Collin 2004) (Catassi, Fabiani et al. 2007), (Hischenhuber 2005)]. One and a half grams to 2 g of daily gluten exposure corresponds to the ingestion of approximately one-half to two-thirds a slice of wheat flour-based bread per day. A drug, to be clinically effective, should be able to significantly reduce or prevent the mucosal deterioration caused by a daily gluten challenge.
A promising new approach to treating celiac disease involves the oral administration of proteases, called glutenases, which can degrade gluten. See PCT Pat. Pub. No. 2003/068170; 2005/107786; 2007/044906; 2007/047303; 2008/115411; and 2010/021752; and U.S. Pat. Nos. 7,303,871; 7,320,788; 7,628,985; 7,910,541; and 7,943,312, each of which is expressly incorporated herein by reference.
Cysteine endoprotease (EP) B2 (also known as EPB2), a barley derived protease, and other similar proteases derived from the germinating seeds of the gluten-containing cereals have been identified as effective agents for the detoxification of gluten, the causative agent in celiac disease (including Celiac sprue and dermatitis herpetiformis; see U.S. Pat. No. 7,303,871, incorporated herein by reference). A modified, recombinant form of the barley-derived EPB2 zymogen called “ALV001” (the active form of this enzyme is termed “ALV001* herein) has been used as part of a combination enzyme therapy (including a prolyl endopeptidase (PEP), such as Sphingomonas capsulata PEP) for oral administration to celiac disease patients to aid in the digestion of gluten before it can exert its toxic effects in these patients (see U.S. Pat. No. 7,320,788; U.S. Pat. App. Pub. No. 20080193436; PCT Patent Pub. Nos. 2008/115428; 2008/115411; 2010/021752; and 2010/042203, each of which is expressly incorporated herein by reference). The ALV001 zymogen becomes active (converts to ALV001*) below pH 5, but is not activated at a higher pH.
ALV003 is an especially promising new drug in clinical development that is a mixture of two glutenases. See PCT Pat. Pub. Nos. 2005/107786; 2008/115428; 2008/115411; 2010/021752; and 2010/042203, each of which is expressly incorporated herein by reference. Oral glutenases such as ALV003 help to proteolyze the immunoreactive gluten peptides present in food before they can trigger an immune response in the intestinal mucosa [(Cerf-Bensussan, Matysiak-Budnik et al. 2007), (Piper, Gray et al. 2004), (Gass, Vora et al. 2006), (Pyle, Paaso et al. 2005), (Sollid and Khosla 2005), (Stepniak, Spaenij-Dekking et al. 2006)]. There remains a need for new methods and pharmaceutical compositions that can be used to protect celiac disease patients and other individuals suffering from gluten intolerance from the harmful effects of inadvertent exposure to gluten and to make gluten ingestion safer for them. The present invention meets these needs.
In one aspect, the invention concerns a method for reducing the severity and/or frequency of symptoms or clinical manifestations resulting from gluten ingestion comprising administering to a seropositive patient (defined as being positive in either of anti-TG2 IgA, DGP IgA, or DGP Ig) with symptomatic celiac disease, gluten intolerance, or gluten sensitivity latiglutenase (ALV003) in an amount from about 100 mg to about 1200 mg per day.
In one embodiment, the patient has symptomatic celiac disease.
In another embodiment, the patient is moderately to severely symptomatic.
In a third embodiment, the serology status of the patient is determined prior to ALV003 administration.
In other embodiments, determination of the serology status comprises an antibody test selected from the group consisting of anti-gliadin antibodies (AGA), anti-reticulin antibodies (ARA), IgA anti-human tissue transglutaminase (TTG) antibodies (TG2), IgA anti-endomysial antibodies (EMA), and anti-deamidated gliadin peptide (DPG) tests.
In a further embodiment, the patient is seropositive.
In a still further embodiment, the patient remains seropositive despite adhering to a gluten-free diet.
In various embodiments, the symptoms may be self-reported.
In another embodiment, the patient has experienced moderately to severe symptoms of celiac disease within one month from first administration.
In a specific embodiment, the symptoms of gluten ingestion are selected from the group consisting of abdominal pain, bloating, constipation and tiredness, and the treatment reduces the severity and/or the frequency of at least one symptom selected from the group consisting of abdominal pain, bloating, constipation and tiredness.
In one embodiment, the symptom is abdominal pain.
In a second embodiment, the symptom is bloating.
In a third embodiment, the symptom is constipation
In a fourth embodiment, the symptom is tiredness or fatigue.
In another embodiment, the daily dose administered is 1200 mg of ALV003.
In another embodiment, the daily dose administered is 900 mg of ALV003.
In a further embodiment, the daily dose administered is 600 mg of ALV003.
In various embodiments administration occurs at mealtime.
The dose may, for example, be administered with a major meal, such as with major meals three times per day.
For example, the daily amount may be administered in one or more doses taken with food.
In one embodiment, the dose is administered at least once a day for at least a month.
In another embodiment, the dose is administered at least 300 days per year for at least two years.
In yet another embodiment, each dose comprises a dose of ALV001 in powdered form and a dose of ALV002 in powdered form, and the powders are dissolved in a potable liquid to be ingested by the patient.
In a further embodiments, the dose is administered with food containing at least 20 mg but not more than 20 g of gluten, or with food containing no more than about 1 g of gluten, or with food containing no more than about 5 g of gluten, or with food containing no more than about 10 g of gluten.
In another aspect, the invention concerns an article of manufacture comprising a container with latiglutenase (ALV300) therein, and a package insert, wherein the package insert provides instructions to administer latiglutenase (ALV300) for reducing the severity and/or frequency of symptoms or clinical manifestations resulting from gluten ingestion in a seropositive patient with symptomatic celiac disease, gluten intolerance, or gluten sensitivity.
In one embodiment, the symptoms of gluten ingestion are selected from the group consisting of abdominal pain, bloating, constipation and tiredness.
In a further aspect, the invention concerns the use of latiglutenase (ALV003) in the preparation of a medicament for reducing the severity and/or frequency of symptoms or clinical manifestations resulting from gluten ingestion in a seropositive patient with symptomatic celiac disease, gluten intolerance, or gluten sensitivity.
In a still further embodiment, the invention concerns a medicament comprising latiglutenase (ALV003) for use in reducing the severity and/or frequency of symptoms or clinical manifestations resulting from gluten ingestion in a seropositive patient with symptomatic celiac disease, gluten intolerance, or gluten sensitivity.
In all aspects, the symptoms and clinical manifestations resulting from gluten ingestion preferably are, or include, abdominal pain, bloating, constipation and/or tiredness.
The invention is best understood from the following detailed description when read in conjunction with the accompanying drawings. It is emphasized that, according to common practice, the various features of the drawings are not to-scale. On the contrary, the dimensions of the various features are arbitrarily expanded or reduced for clarity. Included in the drawings are the following figures.
The term “ALV-1” or “ALV001” is used herein to refer to a zymogenic proenzyme form of cysteine endoprotease B, isoform 1 (EP-B2), naturally occurring in barley. The term, as used herein, specifically includes the polypeptide of SEQ ID NO: 1, with or without the highlighted, vector-derived N- and/or C-terminal residues and with and without the His tags incorporated in the N- and/or C-terminal sequences. The definition further includes post-translational modifications of the proenzyme. In the Examples, “ALV001” is used to refer to the recombinant form of the proenzyme.
The term “ALV-1*” or “ALV001*” is used herein to refer to an active form of the proenzyme ALV-1, as hereinabove defined. The term, as used herein, specifically includes the polypeptide of SEQ ID NO: 2, with or without the highlighted vector-derived C-terminal residues and with or without the C-terminal His tags. In the Examples, “ALV001*” is used to refer to the recombinant form of the active enzyme, which is a modified recombinant version of cysteine endoprotease B, isoform 2 from barley (Hordeum vulgare).
The term “ALV-2” or “ALV002” is used herein to refer to a recombinant version of a prolyl endopeptidase from the bacterium Sphingomonas capsulata (SC-PEP). The term, as used herein, expressly includes the 741 amino acid commercial form of ALV002 (SEQ ID NO:3), with or without the six contiguous histidine residues (hexa-His tag) added in the N-terminal region, and with or without the 38 N-terminal amino acids removed during proteolytic processing.
The terms “ALV-3”, “ALV003”, “IMGX-003” and “latiglutenase” are used interchangeably, and refer to a combination and/or co-administration of ALV-1 and ALV-2 or ALV-1* and ALV-2 or (ALV-1 and ALV-1*) and ALV-2 in a 1:1 (w/w) ratio. In one embodiment, ALV-1 and ALV-2 or ALV-1* and ALV-2 or (ALV-1 and ALV-1*) and ALV-2 are present in the same formulation/dosage form in 1:1 (w/w) ratio (and the formulation/dosage form may include either a formulation in which the two enzymes are admixed or otherwise combined in a single unit dosage form or a formulation in which the two enzymes are in separate dosage form for co-administration). Unless expressly indicated otherwise, the term “ALV-3”, “ALV003”, “IMGX-003” and “latiglutenase” includes combinations comprising ALV-1 and/or ALV-1*. In the Examples, “ALV003”, “IMGX-003” and “latiglutenase” are used to refer to a combination or co-administration of the recombinant forms of ALV001 and/or ALV001* and ALV002.
The term “ALV001/ALV001*” is used herein to mean that either ALV001 or ALV001* can be used.
The terms “celiac sprue” and “celiac disease” are used interchangeably and refer to an autoimmune disease of the small intestine caused by the ingestion of gluten proteins from widely prevalent food sources such as wheat. The terms, as used herein, specifically include clinically silent celiac disease, characterized by absence of gastrointestinal symptoms, and moderate to severe symptomatic celiac disease, characterized by gastrointestinal symptoms that can range from mild to severe. “Celiac disease” as used herein also includes dermatitis herpetiformis.
The term “deleterious effect of gluten ingestion” is used herein to refer to any and all undesired effects of gluten ingestion in a subject, including, without limitation, symptoms and deleterious effects resulting from T lymphocyte-driven immune response in the intestine of celiac disease patients, including gastrointestinal symptoms, such as gluten-induced small intestinal mucosal inflammation and symptoms. The term “deleterious effect of gluten ingestion” also includes any undesired effects of gluten ingestion on the skin of a subject, including, without limitation, symptoms characteristic of dermatitis herpetiformis. The term “deleterious effect of gluten ingestion” specifically includes all symptoms associated with and clinical manifestations of celiac disease, gluten intolerance, or gluten sensitivity, as disclosed herein.
A patient reported outcome (PRO) instrument as used herein, refers to a questionnaire, diary, or any other form of media that can be used to obtain verbal or recorded, e.g. written, typed or tactile, PRO data from a subject. A PRO instrument can be designed to include one or more questions that have been vetted to optimize the form (e.g., graphical; textual or a combination thereof), phrasing or timing of the question to a subject in order to acquire PRO data that is more likely to be valid as compared to data acquired from a non-vetted question. A PRO instrument can be encoded as a computer-executable instruction to be performed on a PRO device. The PRO instrument specifically includes, without limitation, the Celiac Disease Symptom Diary (CDSD) shown in
A “clinical trial” as used herein, refers to an experimental trial or test on one or more subjects designed to determine the safety, efficacy, or basis of a label claim for a medical product. A clinical trial includes administering a medical product or a placebo to one or more subjects.
A “clinical endpoint” as used herein, refers to occurrence of, or change in, a disease, a condition, a syndrome, a symptom, a sign or a laboratory measurement in a subject that constitutes one of the target outcomes of a clinical trial.
A “surrogate endpoint” as used herein, is a measure of an effect of a medical product in a clinical trial on a human or non-human subject that correlates with a real clinical endpoint. The surrogate endpoint can be the presence, absence or change in the level of a biomarker.
A “clinical trial endpoint” as used herein, includes both a clinical endpoint and a surrogate endpoint.
A “computer-executable instruction” as used herein, refers to an instruction or a set of instructions able to operate a computer processor to achieve a desired functional result. The desired functional result can be simple, such as the storage of a value in memory, or complex, such as an invocation of an advanced programming interface (API) call that produces sophisticated functionality. The instruction set can be any suitable processor-executable instruction set, including, without limitation, a native machine architecture language, machine language, Java, JavaScript, BASIC, Visual BASIC, C, C++, C#, FORTRAN, Perl, and the like.
The term “PRO device” is used herein in the broadest sense and refers to a device which is used to administer a PRO instrument to a subject to acquire PRO data, including. A PRO device can be, without limitation, a voice recorder, a fax machine, a portable or a fixed electronic device such as a desktop computer or work station terminal.
ALV003 Mechanism of Action
Gluten has a high proline and glutamine content. This makes it resistant to proteolysis by gastric, pancreatic, and intestinal brush border endo- and exoproteases, which have poor specificity for peptide bonds adjacent to proline and glutamine residues (See (Hausch, Shan et al. 2002), (Shan, Molberg et al. 2002), (Piper, Gray et al. 2004)). As a consequence of the incomplete gastrointestinal proteolysis of gluten, long oligopeptides (such as the 33-mer and 26-mer peptide fragments) accumulate in the small intestine of mammals following ingestion of gluten. Following deamidation by tissue transglutaminase in the intestine, these peptides stimulate an immune response in the intestine of celiac disease patients resulting in structural changes to the lining of the small intestine (Kagnoff 2007). Following the seminal work by Khosla et al. described in PCT Pat. Pub. No. 2003/068170, a number of scientific journal publications have reported the potential for proline- and glutamine-specific endoproteases, referred to as glutenases, as therapeutic agents for celiac disease because of their ability to digest these proteolytically resistant gluten epitopes [(Marti, Molberg et al. 2005), (Shan, Qiao et al. 2005), (Bethune, Strop et al. 2006), (Gass, Vora et al. 2006), (Siegel, Bethune et al. 2006), (Cerf-Bensussan, Matysiak-Budnik et al. 2007), (Gass, Bethune et al. 2007)].
ALV003 is a mixture of two glutenases. The two glutenases that are comprised in ALV003 demonstrate complementary substrate sequence and chain length specificity. If ALV003 comprises the proenzyme form of EPB2, ALV001, upon activation in an acidic environment (as in the stomach) to form ALV001*, proteolyzes gluten at specific glutamine residues and reduces the amount of peptides that are immunostimulatory to T cells derived from celiac disease patients [(Siegel, Bethune et al. 2006), (Bethune, Strop et al. 2006)]. Although ALV002 alone has relatively weak activity on intact gluten proteins, it proteolyzes the peptidic products of ALV001 digestion by cleaving at proline residues [(Shan, Marti et al. 2004), (Gass, Bethune et al. 2007)]. By virtue of their complementary sequence specificity and chain length tolerance for peptides, together ALV001/ALV001* and ALV002 degrade gluten more rapidly and thoroughly than either individual enzyme alone (Gass, Bethune et al. 2007).
The complementary substrate sequence and chain length specificity described above have been demonstrated in vitro and in vivo. ALV003 proteolyzes various forms of gluten (purified gliadin, uncooked gluten flour, and whole wheat bread gluten) in vitro and eliminates >90% of immunoreactive epitopes present. In addition, ALV003 proteolyzed both gluten flour and wheat bread in the stomach of a rat in an in vivo model of gluten digestion. As noted above, at pH values typical of a postprandial stomach (3.5-5), ALV001 activates to its mature form ALV001*, which is active and stable over this pH range. ALV002 contributes to gluten digestion above pH 4. Therefore, ALV003 is active in the stomach during and following a meal. In addition, ALV003 is rapidly proteolyzed by pepsin in both simulated and fasting human gastric fluid (pH 1.8) and also by pancreatin at near neutral pH, providing a mechanism for ALV003 clearance. When incubated in human gastric samples obtained from subjects who had ingested soy milk ex vivo, ALV003 degraded gluten immunoreactive epitopes measured within 30 minutes in a dose-dependent fashion. In vitro, concentrations of ALV003 from 0.25-2.0 mg/mL were able to eliminate >90% of immunoreactive gluten peptides from 0.5-12 mg/mL gluten within 60 min.
Notable favorable properties of ALV003 include its high specificity for gluten and suitability for convenient oral dosing.
Serological Testing to Diagnose Celiac Disease
Celiac disease is characterized by the presence of diverse antibodies in the serum that are made against gliadin, a component of gluten, and connective tissue components, such as tissue transglutaminase antibodies and endomysial antibodies. Tests targeting these antibodies are useful in the diagnosis of celiac disease. In certain embodiments, determination of the serology status of a patient comprises one or more antibody tests selected from the group consisting of anti-gliadin antibodies (AGA), anti-reticulin antibodies (ARA), IgA anti-human tissue transglutaminase (TTG) antibodies (TG2), IgA anti-endomysial antibodies (EMA), and anti-deamidated gliadin peptide (DPG) tests. If at least one of the antibody tests are positive, the patient is considered seropositive.
Pharmaceutical Compositions and Methods of Treatment
Pharmaceutical compositions comprising ALV003, including various formulations for oral administration are known and are described, for example, in WO 2010/021752 and US 2014/0248251-A1, the entire disclosures of which are hereby expressly incorporated by reference. See also, WO 2003/068170; WO 2005/107786; and WO 2008/115411, the disclosures of which are incorporated herein by reference.
In one embodiment, the ALV003 pharmaceutical composition comprises ALV-001, ALV-002, mannitol, potassium citrate, sodium citrate, citric acid, sucrose, TRIS-HCl, EDTA, cysteine hydrochloride, sodium metabisulfite, monthioglycerol, sodium chloride, sucralose, and natural and artificial flavorings.
According to the present invention, ALV003 and pharmaceutical compositions comprising ALV003 can be used in methods for the severity and/or frequency of symptoms associated with or clinical manifestations of celiac disease, gluten intolerance, or gluten sensitivity.
Clinical manifestations of celiac disease, gluten intolerance, or gluten sensitivity include, without limitation, mild gastrointestinal disturbances, chronic gastrointestinal symptoms, malabsorption, weight loss, isolated iron deficiency anemia, various manifestations outside the gut, such as osteoporosis, peripheral and central nervous system involvement, mild or severe liver disease, infertility problems, and the-gluten-induced skin disease, dermatitis herpetiformis. The gluten-induced small bowel pathology in celiac disease is characterized by an inflammatory reaction that is accompanied by villus atrophy and hypertrophy of crypts.
Symptoms of celiac disease, gluten intolerance, or gluten sensitivity include, without limitation, diarrhea, constipation, flatulence, abdominal pain, bloating, nausea, fatigue, tiredness, skin rashes, difficulty thinking, and headache.
Symptoms may range from mild through moderate to severe. The severity of symptoms and/or clinical manifestations can be assessed by patient reported outcome (PRO) instruments, such as, for example, those described in US 2015/0223747 A1, the entire disclosure of which is hereby expressly incorporated by reference. In brief, this PRO instrument may be in the form of a daily or weekly questionnaire that prompts the subject to provide a rating of the extent to which the subject's symptoms have affected the subject's daily life, social activities, emotional wellbeing, and physical functioning. In one embodiment, the PRO instrument also prompts the subject to provide the rating in the form of one of five possible rates, from “not at all” to “completely”, with optional rates of “a little”, “moderately”, and “very much” (or equivalents thereto). In various embodiments, the PRO instrument may be provided in the form of a bi-weekly or monthly questionnaire or simply to provide a point in time evaluation (no specific time period specified). This PRO instrument, called a “Celiac Disease Symptom Diary”, which may be referred to herein as an “CDSD”, has a variety of applications, including but not limited to: to measure symptoms in a clinical trial of a drug or other therapy to treat celiac disease, gluten intolerance, or gluten sensitivity, including but not limited to measuring symptoms in connection with a clinical trial endpoint; to measure symptoms to determine if a subject should be treated for celiac disease, gluten intolerance, or gluten sensitivity; to monitor the status of a patient's condition over time; to identify subjects that should be tested for celiac disease; to monitor the efficacy of a treatment; to determine if a subject should be treated, including but not limited to providing an economic rationale for such treatment, for celiac disease, gluten intolerance, or gluten sensitivity; and to aid a physician in determining or monitoring the health status of a patient that may have celiac disease, gluten intolerance, or gluten sensitivity.
While the PRO instrument, called an “Celiac Disease Symptom Diary” (CDSD) is preferred for measuring the severity and frequency of symptoms, other PRO instruments are also available and can be used, including, for example, PROs that have focused on patient's health-related quality of life.
The PRO instruments used herein specifically include the Celiac Disease Symptom Diary (CDSD), Impact of Celiac Disease Symptoms Questionnaire (ICDSQ), the Patient Global Impressions-Symptoms (PGI-S) & Impact (PGI-I) Questionnaire, and the Short Form 12-v2 Health Survey (SF-12v2) Questionnaire described in the Example (
The severity of the disease can also be determined using medical diagnostic methods known in the art, such as upper gastrointestinal endoscopies, biopsies, small intestinal mucosal morphometric analyses, determination of the villus height/crypt depth ratio to establish manifest gluten-induced mucosal architectural change, and measuring the intraepithelial densities of all CD3+(T) lymphocytes and densities of αβ+ and γδ+ T cell receptor-bearing IELs to reveal gluten-induced inflammatory changes.
While thrice daily (TID) administration is contemplated in various embodiments of the invention, QD administration may also be practiced, i.e., when a patient is consuming only one gluten-containing (or potentially gluten-containing) meal per day. Thus, ALV003 may be administered when a patient is ingesting food suspected of containing, or known to contain, gluten.
Optionally, the patient's serology status may be determined prior to administration of the compositions herein. Determination of the serology status may comprise an antibody test, such as anti-gliadin antibodies (AGA), anti-reticulin antibodies (ARA), IgA anti-human tissue transglutaminase (TTG) antibodies (TG2), and IgA anti-endomysial antibodies (EMA), and anti-deamidated gliadin peptide (DGP) tests.
Administration may occur at mealtime, such as with a major meal or meals, e.g. one to three times, such as three times, per day.
A typical daily dose for oral administration of ALV003 is in the range of about 100 mg to about 3 g, such as, for example, 100 mg, 300 mg, 450 mg, 600 mg, 900 mg, or 1200 mg. As discussed earlier, the daily dose can be reached by one or more administrations, typically taken with food.
People eating an average Western diet ingest approximately 15-25 g gluten per day; a typical slice of whole-wheat bread contains approximately 4-5 g of gluten. In various embodiments, ALV003 is administered with food containing at least about 15 mg, or at least about 20 mg, but not more than about 25 g of gluten, or no more than about 1 g of gluten, or no more than about 2 g of gluten, or no more than about 3 g of gluten, or no more than about 5 g of gluten, or no more than about 10 g of gluten.
In another embodiment, ALV003 has equal amounts of (ALV001 and/or ALV001*), and ALV002, by weight or by units of activity, including embodiments wherein ALV001/ALV-001* has a specific activity of at least 5000 or more proteolytic activity units per mg, and said ALV002 has a specific activity of at least 3000 or more proteolytic activity units per mg.
Further details of the invention will be illustrated by the following non-limiting examples.
All references cited throughout the disclosure are hereby expressly incorporated by reference in their entirety.
ALV003-1221, a Phase 2b, Randomized, Double-Blind, Placebo-Controlled Dose-Ranging Study of the Efficacy and Safety of ALV003 Treatment in Symptomatic Celiac Disease Patients Maintained on a Gluten-Free Diet
Celiac disease (CD) is an autoimmune disease triggered by the ingestion of gluten that often causes severe gastrointestinal symptoms for those afflicted with the disease. At present, there is no available treatment other than a gluten-free diet (GFD), which is very difficult to achieve and many patients continue to experience significant symptoms.
The present ALV003-1221 clinical trial (NCT01917630) investigated the effectiveness of latiglutenase (ALV-003), an orally administered mixture of two recombinant gluten-specific digestive enzymes, for reducing major symptoms resulting from inadvertent gluten ingestion. In particular, ALV003-1221 was a double-blind, placebo-controlled, dose-ranging clinical study that assessed the efficacy and safety of latiglutenase (ALV003) in symptomatic, established, celiac disease (CD) patients who reported following a GFD for at least one year prior to randomization. Patients with documented moderate or severe symptoms and villous atrophy, villus height:crypt depth (Vh:Cd)≤2.0 (typically), were randomized to placebo or active treatment for 12 or 24 weeks and then underwent follow-up duodenal biopsy. Symptoms were recorded daily throughout the study.
Eligibility Criteria
Ages Eligible for Study: 18 Years to 80 Years
Genders Eligible for Study: Both
Inclusion Criteria:
Exclusion Criteria:
Study Design
Patients were randomized to one of six treatment groups: Placebo (PBO), ALV003 100 mg (A100), ALV003 300 mg (A300), ALV003 450 mg (A450), ALV003 600 mg (A600), and ALV003 900 mg (A900). Patients were allocated by dose level approximately in a 3:1:2:1:2:1 ratio. Table I shows the distribution of completed patients who were seronegative and seropositive for each treatment group. Seropositive status was determined by any one of the following tests exceeding a threshold value; anti-TG2 IgA, DGP IgA, DGP IgG.
Completed Patient Sample Size
A statistical analysis was performed assessing objectives related to the quality of life of patient-reported outcomes. The objectives of this analysis were as follows:
Patient-Reported Outcome Instruments and Scoring
Celiac Disease Symptom Diary (CDSD)
The CDSD is a daily diary administered across a seven-day period that assesses common celiac symptoms (diarrhea, constipation, abdominal pain, bloating, nausea, and tiredness). The presence or absence of each of the symptoms over the previous 24 hours is reported. If the respondent indicates the presence of a particular symptom, contingent follow-up questions are asked to assess the symptom severity for that particular symptom. See
For each daily diary entry, the presence of each symptom will be indicated as the following responses to the questions: diarrhea (Q1=1), constipation (Q2=1; i.e., the absence of a constipation), abdominal pain (Q3=1), bloating (Q4=1), nausea (Q5=1), tiredness (Q6=1).
For each symptom, within the given study week (7 days), a weekly frequency score will be calculated by summing the number of times during the week each symptom was indicated. Thus, for each symptom, the weekly frequency score will range from 0 (never indicating the symptom during the study week) to 7 (indicating the symptom every day of the study week).
It should be stated explicitly, however, that the clinical definition of constipation generally requires a week of follow up (i.e., less than 3 complete spontaneous bowel movements within a 1-week timeframe). Hence, the weekly frequency score for Q2 will represent the number of days during the week where the patient did not have any complete spontaneous bowel movements, rather than the number of days where the patient was constipated in a strict clinical sense.
An overall symptom frequency score will also be computed that will be equal to the number of days in the week (range: 0 to 7) where any of the gastrointestinal symptoms (Q1, Q2, Q3, Q4, and/or Q5) was indicated. The tiredness symptom (Q6) will not be included in the calculation of the overall symptom frequency score.
Each time the patient indicates a particular symptom in the daily diary, a follow-up question will be asked about severity. For each symptom, with the exception of constipation, a daily severity score will be computed as follows:
For each of the above symptoms, if the contingent question criterion is not met, then the daily severity score will be assigned a value of 0. Thus, each daily symptom score will be on a 0 to 10 scale. For each symptom, within the given study week (7 days), a weekly severity score will be calculated by summing the daily severity scores (range: 0 to 10) over the week, which will yield a range of 0 to 70 for each weekly symptom severity score.
For constipation, the weekly severity score will be calculated by pooling together data across the entire study week (rather than calculating daily severity scores then summing to compute a weekly severity score). Based on the responses to Q2a, if the patient indicates 3 or more complete spontaneous bowel movements (CSBMs) taking together all days across the particular study week, then the weekly severity score will be set to 0 (i.e., no constipation). Otherwise, if the patient reports less than 3 complete spontaneous bowel movements taking together all the days across the particular study week, the weekly severity score will be calculated as follows:
Constipation Weekly Severity=[(−31.5)*(Weekly number of CSBMs)]+70;
(contingent upon Weekly number of CSMBs<3)
Hence, the Constipation Weekly Severity score will range from 0 to 70 based on the number of complete spontaneous bowel movements that the patient indicates across the entire study week.
A weekly Overall Severity Score will be calculated by summing the weekly severity scores of the five gastrointestinal symptoms (Diarrhea Severity, Constipation Severity, Abdominal Pain Severity, Bloating Severity, Nausea Severity). Thus, the Overall Severity Score will range from 0 to 350.
Impact of Celiac Disease Symptoms Questionnaire (ICDSQ)
The ICDSQ will be used to assess the impact of patients' celiac symptoms over the previous week at Visit 4 (Day 1), Visit 5 (Week 6), Visit 6 (Week 12), and at Visit 7 (Week 18) and Visit 8 (Week 24) for those patients participating in Study Period 3. The questionnaire has a 7-day recall period and is comprised of 14 items with four domains: Daily Activities (4 items), Social Activities (3 items), Emotional Well-being (5 items) and Physical Functioning (2 items).
Each item has five response options ranging from 0 (“not at all”) to 4 (“completely”). Each domain will be scored by computing the mean of the domain items. An overall ICDSQ score will be calculated by summing the four mean domain scores. See
Patient Global Impression-Symptoms (PGI-S)
Although the PGI-S will not be analyzed as an outcome, it will be used to define responder categories for the CDSD (as described in the Statistical Methods section below). The PGI-S is a single global assessment item that asks participants to rate the severity of their celiac symptoms over the previous seven days on a 6-point scale (0=“I have not had any symptoms” to 5=“very severe”). See
Short Form-12v2 (SF-12v2(Health Survey)
The SF-12v2 Health Survey is a shorter version of the SF-36 Health Survey that will ask patients to answer 12 questions that measure physical and mental health at Day 1, Week 6, Week 12, and at Week 18 and Week 24 for those patients participating in Study Period 3. The SF-12v2 covers eight health domains (Physical Functioning, Role Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role Emotional, and Mental Health) which comprise two component summary measures (Physical Component Summary and Mental Component Summary). All scores range from 0 to 100.
The SF-12v2 will be scored using the QualityMetric algorithm. Additionally the SF-6D Utility Index will be calculated. Scoring algorithm details along with a description of the SF-12v2 instrument itself have been previously described (Ware 2002). See
All data analyses were generated using SAS software, Version 9.2 of the SAS System for Windows or higher. Copyright ©2003 SAS Institute Inc. See also, Ware J E Jr, Kosinski M, Turner-Bowker D M, Gandek B. How to Score Version 2 of the SF-12 Health Survey (With a Supplement Documenting Version 1). Lincoln, R.I.: QualityMetric Incorporated, 2002.
CDSD Severity and Frequency Analysis
Dose Dependence:
RISdose (%)=[(ΔBdose/Bdose)−(ΔBPBO/BPBO)]/(1−(ΔBPBO/BPBO) Eq. (1)
where RISdose (%) is the percent reduction in symptoms, Bdose is the baseline value (i.e., the total severity score of the symptom in the week prior to randomization), and ΔBdose is the change in baseline value cumulative for all patients for a particular dose. The subscript PBO represents the placebo dose population. The (1−(ΔBPBO/BPBO)) term in the denominator accounted for the improvement in a symptom due to latiglutenase activity relative to the placebo effect; as a result, RISdose could assume values between 0% (corresponding to the placebo effect) and 100% (full recovery of the symptom).
Table II summarizes the percent improvement for the 600 mg and 900 mg doses (ALV600 and ALV900, respectively) relative to PBO for abdominal pain, bloating and tiredness for week 6 and week 12 using the CDSD severity and frequency data. This analysis is from the same data set plotted in
It is also worth noting that improvement as measured by MS is generally greater for severity than for frequency, which is expected based on the definitions for each. Severity represents the average total score for severity, which inherently has frequency in it whereas frequency does not distinguish the severity of each event. These results indicate that latiglutenase reduces both the frequency of events as well as the severity of each event.
A strong trial effect (more than normal conformance to a gluten-free diet during the trial period) was evident from the objective histologic and this is evident in the subjective symptom PRO data as well as evidenced in
Finally, it is important to note that for nausea and diarrhea where little improvement due to latiglutenase is observed, that there is no evidence of symptom worsening further bolstering the safety of latiglutenase.
CDSD Daily Symptom Analysis
We analyzed the raw data from the CDSD tool. This entailed reporting of events and severity for the six symptom domains for all patients for all days of the trial including the weeks 1-4 baseline period and the weeks 5-8 randomization period. The study then ran for 12 weeks for all patients and another 12 weeks for about a quarter of the completed patients. In this analysis we defined three periods: weeks −8 to 0 (days 1-56), which we used for baseline calculations since the CDSD continued to be administered during the randomization period preceding the start of the trial, weeks 1-6 (days 57-98) of the trial and weeks 7-12 (days 99-140) of the trial.
Individual Plots:
In
Integration Over Time Periods:
We now report on the results of the daily data consolidated for all seropositive patients in the ALV900 and PBO arm. Table III summarizes the frequency of symptom events as a function of severity for abdominal pain, bloating, and tiredness for the ALV900 and PBO seropositive arms. The results are presented for the pre-trial period (days 1-56) and the two halves of the trial period (days 57-98 and 99-140, respectively). The most notable observations are:
There appears to be a trend toward greater symptom improvement relative to PBO the greater the severity of the symptom event. This trend was also observed for the Week 12 average data in
Analysis was also conducted for seronegative patients and there was no significant symptom benefit observed for abdominal pain, bloating, and tiredness. One can also conclude that there was no noticeable worsening in these symptoms for seronegative patients due to the use of latiglutenase, although there is more noise in these data due to small differences between large numbers.
Responder Analysis
We performed a responder analyses on the symptom data. The definition for responder in this work is the percentage of individuals who exceeded a RIS relative to placebo in a symptom domain based on the severity and frequency scales. For RIS threshold we chose ≥50%, but we also calculated for ≥30%, which gave similar results
Quality of Life (QOL) was measured with the ICDSQ, PGI-S, PGI-I, and SF-12v2 instruments.
This application is a 371 application and claims the benefit of PCT Application No. PCT/US2017/062602, filed Nov. 20, 2017, which claims benefit of U.S. Provisional Patent Application No. 62/426,119, filed Nov. 23, 2016, which applications are incorporated herein by reference in their entirety.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US17/62602 | 11/20/2017 | WO | 00 |
| Number | Date | Country | |
|---|---|---|---|
| 62426119 | Nov 2016 | US |
