Patent Application
20220259305
The content of the electronically submitted sequence listing in ASCII text file (Name: 706898_AX9_006PC_ST25_Sequence_Listing.txt; Size: 56 KB; and Date of Creation: Jul. 22, 2020) is incorporated herein by reference in its entirety.
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.
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.
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.
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], cyclosporine, and mycophenolate mofetil [MMF]), the majority of subjects with MG have their disease reasonably well controlled.
However, a proportion of 10-15% of refractory subjects 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. These patients are considered to have refractory MG. Although there is no generally recognized standard definition of ‘refractory’ disease in gMG, criteria for refractory disease that have been used include failure to respond to conventional treatments such as immunosuppressive therapies (ISTs), inability to reduce IST use without clinical relapse, intolerable adverse reactions to conventional treatments, requirement for large doses of potentially harmful agents such as ISTs, presence of comorbidities that contraindicate conventional treatments, requirement for repeated short-term rescue therapy (e.g. intravenous immunoglobulin and plasma exchange), and recurrent myasthenic crises.
A study in two US health plan databases reported 4-fold and 4.7-fold increases in rates of myasthenic crisis/exacerbation, respectively, in refractory versus non-refractory cases. A UK study reported increased healthcare resource use in refractory versus non-refractory MG. Therefore, refractory MG can have a severe impact on the health-related quality of life (QOL) and increase the socioeconomic burden of the disease. It is important, therefore, to consider therapeutic needs in treatment-refractory MG.
The Myasthenia Gravis Foundation of America (MGFA) post-intervention status can be used to evaluate changes in a patient's condition following treatment, including improvement, worsening or no change of clinical manifestations from pretreatment. Patients are considered to have achieved minimal manifestations (MM) if they have no symptoms indicating functional limitations. Those experiencing no symptoms of MG for at least 1 year, apart from isolated ocular muscle weakness, while receiving therapy other than cholinesterase inhibitors, are considered to have achieved pharmacologic remission (PR). There is a consensus within the medical community that achievement of an MGFA post-intervention status of MM or better should be the goal of treatment for patients with MG. To achieve this goal, an alternative therapy is needed.
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 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 treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment.
In one embodiment, the anti-C5 antibody is eculizumab. In another embodiment, 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, 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. In some embodiments, the method further 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. In some embodiments, the method further 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. In some embodiments, the method further 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.
In some embodiments, the therapeutically effective amount of the anti-C5 antibody or antigen binding fragment thereof for treating refractory generalized myasthenia gravis is based on the weight of the subject. In another embodiment, the anti-C5 antibody is ravulizumab. In another embodiment, ravulizumab, or an antigen binding fragment thereof is administered to a patient weighing ≥40 and <60 kg: once on Day 1 of the administration cycle at a loading dose of 2400 mg; and on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3000 mg. In another embodiment, ravulizumab, or an antigen binding fragment thereof is administered to a patient weighing ≥60 and <100 kg: once on Day 1 of the administration cycle at a loading dose of 2700 mg; and on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3300 mg. In another embodiment, ravulizumab, or antigen binding fragment thereof, is administered to a patient weighing ≥100 kg: once on Day 1 of the administration cycle at a loading dose of 3000 mg; and on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3600 mg.
In some embodiments, the patient achieves a MGFA post-intervention status of Improved or MM after 4 weeks of treatment. In some embodiments, the patient achieves a MGFA post-intervention status of Improved or MM after 12 weeks of treatment. In some embodiments, the patient achieves a MGFA post-intervention status of Improved or MM after 26 weeks of treatment. In some embodiments, the patient achieves a MGFA post-intervention status of Improved or MM after 52 weeks of treatment. In some embodiments, the patient achieves a MGFA post-intervention status of Improved or MM after 66 weeks of treatment. In some embodiments, the patient achieves a MGFA post-intervention status of Improved or MM after 78 weeks of treatment. In some embodiments, the patient achieves a MGFA post-intervention status of Improved or MM after 104 weeks of treatment. In some embodiments, the patient achieves a MGFA post-intervention status of Improved or MM after 130 weeks of treatment. In some embodiments, the patient achieves a MGFA post-intervention status of Improved or MM after 156 weeks of treatment. In some embodiments, the patient achieves a MGFA post-intervention status of Improved. In some embodiments the patient achieves a MGFA post-intervention status of MM.
In some embodiments, the patient experiences a clinically meaningful improvement (reduction) in a measurement of generalized myasthenia gravis severity after 26 weeks of treatment selected from the group consisting of Myasthenia Gravis Activities of Daily Living (MG-ADL) score, quantitative Myasthenia Gravis (QMG), score and Myasthenia Gravis Composite (MGC) score. In some embodiments, the clinically meaningful improvement the patient experiences is an at least a 3 point reduction in the patient's MG-ADL score after 26 weeks of treatment. In some embodiments, the clinically meaningful improvement the patient experiences is an at least a 4 point reduction in the patient's QMG score after 26 weeks of treatment. In some embodiments, the clinically meaningful improvement the patient experiences is an at least a 6 point reduction in the patient's MGC score after 26 weeks of treatment. In some embodiments, 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. In some embodiments, the clinically meaningful improvement the patient experiences is an at least a 6 point reduction in the patient's MG-QOL-15 score after 26 weeks of treatment.
In some embodiments, the patient experiences a clinically meaningful improvement (reduction) in neuro-fatigue as measured by Neuro-QOL Fatigue score after 26 weeks of treatment. In some embodiments, the clinically meaningful improvement the patient experiences is an at least an 8 point reduction in the patient's Neuro-QOL score after 26 weeks of treatment. In some embodiments, the patient experiences a clinically meaningful improvement (increase) in health status as measured by EQ-5D health status score after 26 weeks of treatment.
This disclosure further provides a method of treating refractory generalized myasthenia gravis in a patient in need thereof comprising administering an anti-C5 antibody or an antigen binding fragment thereof 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 treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment; 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.
The disclosure further 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 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 the patient is treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment; 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.
In some embodiments, 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.
The disclosure also provides a method of maintaining a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) in a patient with refractory generalized myasthenia gravis 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 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 the patient had achieved the Improved or MM status.
In some embodiments, the improved or MM status is maintained for at least 4, 12, 26, 52, 66, 78, 104, 130 or 156 weeks. In some embodiments, the patient starts the maintenance with the MM status. In other embodiments, the MM status is maintained for at least 4, 12, 26, 52, 66, 78, 104, 130 or 156 weeks.
The following embodiments, apply to any of the disclosures and embodiments described in the Summary above. In some embodiments, eculizumab is administered by intravenous infusion. In some embodiments, eculizumab is administered subcutaneously.
In some embodiments, 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 some embodiments, ravulizumab comprises 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 some embodiments, the patient has failed treatment over one year or more with two or more ISTs in sequence or in combination. In some embodiments, the patient has failed at least one IST and requires chronic plasma exchange or IVIg to control symptoms.
In some embodiments, the therapeutically effective amount of the anti-C5 antibody or antigen binding fragment thereof is maintained at a concentration of between 50-100 μg/mL in the patient's serum.
In some embodiments, the patient experiences a reduction in the administration of one or more IST following at least 26 weeks of treatment. In another embodiment, the patient experiences a reduction in IST dosing following at least 26 weeks of treatment. In some embodiments, 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.
In some embodiments, the anti-C5 antibody or an antigen binding fragment thereof is selected from the group consisting of eculizumab, ravulizumab, BNJ421, 7086 antibody, 8110 antibody, 305LO5, SKY59 and REGN3918. In some embodiments, the patient switches from receiving one anti-C5 antibody or antigen binding fragment thereof to a different anti-C5 antibody or antigen binding fragment thereof during the course of treatment. In other embodiments, the different anti-C5 antibodies may be administered during separate treatment periods.
This disclosure also provides a use for treating refractory generalized myasthenia gravis in a patient in need thereof. In some embodiments 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 the patient is treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment.
In some embodiments, eculizumab is used for administration at 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, 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.
In some embodiments, the use of eculizumab further 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. In some embodiments, the use of eculizumab further 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. In some embodiments, the use of eculizumab further 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. In some embodiments, the use of eculizumab is at a therapeutically effective amount, wherein the therapeutically effective amount is based on the weight of the subject.
In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved or MM after 4 weeks of treatment in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved or MM after 12 weeks of treatment in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved or MM after 26 weeks of treatment in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved or MM after 52 weeks of treatment in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved or MM after 66 weeks of treatment in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved or MM after 78 weeks of treatment in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved or MM after 104 weeks of treatment in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved or MM after 130 weeks of treatment in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved or MM after 156 weeks of treatment in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of Improved in a patient. In some embodiments, eculizumab is for use in achieving a MGFA post-intervention status of MM in a patient.
In some embodiments, the patient experiences a clinically meaningful improvement (reduction) in a measurement of generalized myasthenia gravis severity after 26 weeks of treatment selected from the group consisting of Myasthenia Gravis Activities of Daily Living (MG-ADL) score, quantitative Myasthenia Gravis (QMG), score and Myasthenia Gravis Composite (MGC) score. In some embodiments, the clinically meaningful improvement the patient experiences is an at least a 3 point reduction in the patient's MG-ADL score after 26 weeks of treatment. In some embodiments, the clinically meaningful improvement the patient experiences is an at least a 4 point reduction in the patient's QMG score after 26 weeks of treatment. In some embodiments, the clinically meaningful improvement the patient experiences is an at least a 6 point reduction in the patient's MGC score after 26 weeks of treatment. In some embodiments, 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. In some embodiments, the clinically meaningful improvement the patient experiences is an at least a 6 point reduction in the patient's MG-QOL-15 score after 26 weeks of treatment. In some embodiments, wherein the patient experiences a clinically meaningful improvement (reduction) in neuro-fatigue as measured by Neuro-QOL Fatigue score after 26 weeks of treatment. In some embodiments, the clinically meaningful improvement the patient experiences is an at least an 8 point reduction in the patient's Neuro-QOL score after 26 weeks of treatment. In some embodiments, the patient experiences a clinically meaningful improvement (increase) in health status as measured by EQ-5D health status score after 26 weeks of treatment.
This disclosure also provides a use of eculizumab for 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 the patient is treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment; 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.
In some embodiments, 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, 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. In some embodiments, eculizumab is for use at a therapeutically effective amount, wherein the therapeutically effective amount is based on the weight of the subject.
This disclosure also provides eculizumab for use in 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 the patient is treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment; 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.
In some embodiments, eculizumab is for use at 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, 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. In some embodiments, eculizumab is for use at a therapeutically effective amount, wherein the therapeutically effective amount is based on the weight of the subject. In some embodiments, 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.
This disclosure also provides eculizumab for the use in maintaining a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) in a patient with refractory generalized myasthenia gravis 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 had achieved the Improved or MM status. In some embodiments, eculizumab is for use at 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, 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. In some embodiments, the use of eculizumab further 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. In some embodiments, the use of eculizumab further 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. In some embodiments, the use of eculizumab further 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. In some embodiments, eculizumab is for use at a therapeutically effective amount, wherein the therapeutically effective amount is based on the weight of the subject.
In some embodiments, use of eculizumab results in Improved or MM status is maintained for at least 4, 12, 26, 52, 66, 78, 104, 130 or 156 weeks. In some embodiments, the patient starts the maintenance with the MM status. In some embodiments, the MM status is maintained for at least 4, 12, 26, 52, 66, 78, 104, 130 or 156 weeks. In some embodiments eculizumab is for use by administration by intravenous infusion. In some embodiments eculizumab is for use by subcutaneous administration.
In some embodiments, 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 some embodiments, eculizumab is for use in a patient that has failed treatment over one year or more with two or more ISTs in sequence or in combination. In some embodiments, eculizumab is for use in a patient that has failed at least one IST and requires chronic plasma exchange or IVIg to control symptoms.
In some embodiments, the therapeutically effective amount of eculizumab is maintained at a concentration of between 50-100 μg/mL in the patient's serum.
In some embodiments, the patient experiences a reduction in the administration of one or more IST following at least 26 weeks of treatment. In some embodiments, the patient experiences a reduction in IST dosing following at least 26 weeks of treatment.
In some embodiments, the patient experiences a reduction in IST dosing and a discontinuation in one or more IST following at least 26 of treatment. In some embodiments, the patient switches from receiving one anti-C5 antibody or antigen binding fragment thereof to eculizumab during the course of treatment.
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).
In certain embodiments, the antibody that specifically binds C5 is eculizumab. In more specific embodiments, eculizumab is an antibody or a fragment thereof.
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.
In certain embodiments, the antibody that specifically binds C5 is ravulizumab. Ravulizumab was engineered from eculizumab, a humanized monoclonal antibody that specifically binds with high affinity to the human terminal complement component (C5), inhibiting C5 enzymatic cleavage and thereby preventing the generation of the proinflammatory/prothrombotic complement activation products, C5a, and the cytolytic and proinflammatory/prothrombotic membrane attack complex, C5b-9, which are responsible for the antibody-mediated destruction of the neuromuscular junction (NMJ), loss of acetylcholine receptors, and failure of neuromuscular transmission associated with generalized myasthenia gravis (gMG). Eculizumab is approved for the treatment of gMG, paroxysmal nocturnal hemoglobinuria, neuromyelitis optica spectrum disorders (NMOSD) and/or atypical hemolytic uremic syndrome in many countries worldwide, including the USA, and countries in the European Union under the trade name Soliris®. Ravulizumab is approved for the treatment of paroxysmal nocturnal hemoglobinuria and/or atypical hemolytic uremic syndrome in several countries worldwide, including the USA, the European Union and Japan under the trade name Ultomiris®.
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, such as that described in U.S. Pat. No. 9,732,149, which is hereby incorporated herein by reference in its entirety. 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.
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).
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.
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.
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.
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 1×10−6 M or smaller. In other embodiments, the dissociation constant is at least about 1×10−7 M, 1×10−8 M, 1×10−9 M, or 1×10−10 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.
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.
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 is a humanized monoclonal antibody that is a terminal complement inhibitor.
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.
Empirical data indicate that serum eculizumab concentrations greater than 50 μg/mL and closer to at least 100 μg/mL are required to significantly reduce free C5 concentrations. Specifically, free C5 concentration was reduced significantly with increasing concentrations of eculizumab beginning at >50 μg/mL and was at near zero levels with eculizumab concentrations above 100 μg/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 μg/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 μg/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 μg/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 μg/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 μg/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 μg/mL of eculizumab in serum of the subject.
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.
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.
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 μg/mL, between 60-100 μg/mL, between 70-100 μg/mL, between 80-100 μg/mL, or between 90-100 μg/mL of eculizumab in serum of the subject.
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.
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.
Another exemplary anti-C5 antibody is an eculizumab variant, known as antibody BNJ441, also known as ravulizumab, and engineered to have a longer half-life (T½) 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 (ravulizumab) is a humanized monoclonal antibody that is structurally related to eculizumab (SOLIRIS®). 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.
In other embodiments, the antibody comprises the heavy and light chain CDRs or variable regions of BNJ441 (also known as ravulizumab, and Ultomiris®). 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.
In certain embodiments ravulizumab is administered once on Day 1 of the administration cycle, once on Day 15 of the administration cycle, and every eight weeks thereafter. In one embodiment, the anti-C5 antibody, or antigen binding fragment thereof, is administered every eight weeks after the administration cycle for an extension period up to two years (e.g., at a dose of 3000 mg, 3300 mg, or 3600 mg).
In another embodiment, ravulizumab is administered for one or more administration cycles. In one embodiment, the administration cycle is 26 weeks. In another embodiment, the treatment comprises at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11 cycles. In another embodiment, the treatment is continued for the lifetime of the human patient.
In another embodiment, a method of treating a human patient is provided, the method comprising administering to the patient during an administration cycle an effective amount of ravulizumab, or antigen binding fragment thereof, wherein ravulizumab is administered: once on Day 1 of the administration cycle at a dose of: 2400 mg to a patient weighing ≥40 to <60 kg, 2700 mg to a patient weighing ≥60 to <100 kg, or 3000 mg to a patient weighing ≥100 kg; and on Day 15 of the administration cycle and every eight weeks thereafter at a dose of 3000 mg to a patient weighing ≥40 to <60 kg, 3300 mg to a patient weighing ≥60 to <100 kg, or 3600 mg to a patient weighing ≥100 kg.
In certain embodiments, the dose of anti-C5 antibodies, or antigen binding fragment thereof, is based on the weight of the patient. For example, in one embodiment, about 2400 mg, about 2700 mg, about 3000 mg, about 3300 mg, and/or about 3600 mg of ravulizumab, or antigen binding fragment thereof, is administered to a patient based on their weight. In one embodiment, 2400 mg or 3000 mg of ravulizumab, or antigen binding fragment thereof, is administered to a patient weighing ≥40 to <60 kg. In another embodiment, 2700 mg or 3300 mg of ravulizumab, or antigen binding fragment thereof, is administered to a patient weighing 2 60 to <100 kg. In another embodiment, 3000 mg or 3600 mg of ravulizumab, or antigen binding fragment thereof, is administered to a patient weighing ≥100 kg. In certain embodiments, dosage regimens are adjusted to provide the optimum desired response (e.g., an effective response).
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.
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.
In another embodiment, an exemplary anti C5 antibody is the 305LO5 antibody described in US2016/0176954A1. The anti-C5 antibody can comprise, for example, the heavy and light chain CDRs or variable regions of the 305LO5 antibody. The anti C5 antibody can comprise, for example, heavy chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs: 37, 38 and 39, respectively, and light chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs: 40, 41 and 42, respectively. In another embodiment, the antibody comprises the VH region of the 305LO5 antibody having the sequence set forth in SEQ ID NO: 43, and the VL region of the 305LO5 antibody having the sequence set forth in SEQ ID NO: 44.
Another exemplary anti-C5 antibody is the SKY59 antibody (Fukuzawa, T. et al., Sci. Rep., 7:1080, 2017). The anti-C5 antibody can comprise, for example, the heavy and light chain CDRs or variable regions of the SKY59 antibody. The anti-C5 antibody can comprise, for example, a heavy chain comprising SEQ ID NO:45 and a light chain comprising SEQ ID NO:46.
Another exemplary anti-C5 antibody is the REGN3918 antibody (also known as H4H12166PP) described in US20170355757. The anti-C5 antibody can comprise, for example, a heavy chain variable region comprising SEQ ID NO:47 and a light chain variable region comprising SEQ ID NO:48, or a heavy chain comprising SEQ ID NO:49 and a light chain comprising SEQ ID NO:50.
Another exemplary anti-C5 antibody comprises a heavy chain variable region amino acid sequence according to SEQ ID NO: 51 and a light chain variable region amino acid sequence according to SEQ ID NO: 52.
In another embodiment, the antibody competes for binding with, and/or binds to the same epitope on C5 as, the above-mentioned antibodies (e.g., eculizumab, ravulizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). The anti-C5 antibody can have, for example, at least about 90% variable region amino acid sequence identity with the above-mentioned antibodies (e.g., at least about 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98% or 99% variable region identity).
An anti-C5 antibody described herein can, in some embodiments, comprise a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn) with greater affinity than that of the native human Fc constant region from which the variant human Fc constant region was derived. The Fc constant region can comprise, for example, one or more (e.g., two, three, four, five, six, seven, or eight or more) amino acid substitutions relative to the native human Fc constant region from which the variant human Fc constant region was derived. The substitutions, for example, can increase the binding affinity of an IgG antibody containing the variant Fc constant region to FcRn at pH 6.0, while maintaining the pH dependence of the interaction. Methods for testing whether one or more substitutions in the Fc constant region of an antibody increase the affinity of the Fc constant region for FcRn at pH 6.0 are known in the art and exemplified in the working examples (PCT/US2015/019225 and U.S. Pat. No. 9,079,949 the disclosures of each of which are incorporated herein by reference in their entirety).
Substitutions that enhance the binding affinity of an antibody Fc constant region for FcRn are known in the art and include, e.g., (1) the M252Y/S254T/T256E triple substitution (Dall'Acqua, W. et al., J. Biol. Chem., 281: 23514 24, 2006); (2) the M428L or T250Q/M428L substitutions (Hinton, P. et al., J. Biol. Chem., 279:6213 6, 2004; Hinton, P. et al., J. Immunol., 176:346 56, 2006); and (3) the N434A or T307/E380A/N434A substitutions (Petkova, S. et al., Int. Immunol., 18:1759 69, 2006). Additional substitution pairings, e.g., P257I/Q311I, P257I/N434H, and D376V/N434H, have also been described (Datta-Mannan, A. et al., J. Biol. Chem., 282:1709 17, 2007). The entire teachings of each of the cited references are hereby incorporated by reference.
In some embodiments, the variant constant region has a substitution at EU amino acid residue 255 for valine. In some embodiments, the variant constant region has a substitution at EU amino acid residue 309 for asparagine. In some embodiments, the variant constant region has a substitution at EU amino acid residue 312 for isoleucine. In some embodiments, the variant constant region has a substitution at EU amino acid residue 386.
In some embodiments, the variant Fc constant region comprises no more than 30 (e.g., no more than 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, nine, eight, seven, six, five, four, three or two) amino acid substitutions, insertions or deletions relative to the native constant region from which it was derived. In some embodiments, the variant Fc constant region comprises one or more amino acid substitutions selected from the group consisting of: M252Y, S254T, T256E, N434S, M428L, V259I, T250I and V308F. In some embodiments, the variant human Fc constant region comprises a methionine at position 428 and an asparagine at position 434, each in EU numbering. In some embodiments, the variant Fc constant region comprises a 428L/434S double substitution as described in, e.g., U.S. Pat. No. 8,088,376 the disclosure of which is incorporated herein by reference in its entirety.
In some embodiments the precise location of these mutations may be shifted from the native human Fc constant region position due to antibody engineering. The 428L/434S double substitution when used in a IgG2/4 chimeric Fc, for example, may correspond to 429L and 435S as in the M429L and N435S variants found in ravulizumab and described in U.S. Pat. No. 9,079,949 the disclosure of which is incorporated herein by reference in its entirety.
In some embodiments, the variant constant region comprises a substitution at amino acid position 237, 238, 239, 248, 250, 252, 254, 255, 256, 257, 258, 265, 270, 286, 289, 297, 298, 303, 305, 307, 308, 309, 311, 312, 314, 315, 317, 325, 332, 334, 360, 376, 380, 382, 384, 385, 386, 387, 389, 424, 428, 433, 434 or 436 (EU numbering) relative to the native human Fc constant region. In some embodiments, the substitution is selected from the group consisting of: methionine for glycine at position 237; alanine for proline at position 238; lysine for serine at position 239; isoleucine for lysine at position 248; alanine, phenylalanine, isoleucine, methionine, glutamine, serine, valine, tryptophan or tyrosine for threonine at position 250; phenylalanine, tryptophan or tyrosine for methionine at position 252; threonine for serine at position 254; glutamic acid for arginine at position 255; aspartic acid, glutamic acid or glutamine for threonine at position 256; alanine, glycine, isoleucine, leucine, methionine, asparagine, serine, threonine or valine for proline at position 257; histidine for glutamic acid at position 258; alanine for aspartic acid at position 265; phenylalanine for aspartic acid at position 270; alanine or glutamic acid for asparagine at position 286; histidine for threonine at position 289; alanine for asparagine at position 297; glycine for serine at position 298; alanine for valine at position 303; alanine for valine at position 305; alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, methionine, asparagine, proline, glutamine, arginine, serine, valine, tryptophan or tyrosine for threonine at position 307; alanine, phenylalanine, isoleucine, leucine, methionine, proline, glutamine or threonine for valine at position 308; alanine, aspartic acid, glutamic acid, proline or arginine for leucine or valine at position 309; alanine, histidine or isoleucine for glutamine at position 311; alanine or histidine for aspartic acid at position 312; lysine or arginine for leucine at position 314, alanine or histidine for asparagine at position 315; alanine for lysine at position 317; glycine for asparagine at position 325; valine for isoleucine at position 332; leucine for lysine at position 334: histidine for lysine at position 360; alanine for aspartic acid at position 376; alanine for glutamic acid at position 380; alanine for glutamic acid at position 382; alanine for asparagine or serine at position 384; aspartic acid or histidine for glycine at position 385; proline for glutamine at position 386; glutamic acid for proline at position 387: alanine or serine for asparagine at position 389; alanine for serine at position 424; alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, asparagine, proline, glutamine, serine, threonine, valine, tryptophan or tyrosine for methionine at position 428; lysine for histidine at position 433; alanine, phenylalanine, histidine, serine, tryptophan or tyrosine for asparagine at position 434; and histidine for tyrosine or phenylalanine at position 436, all in EU numbering.
In one embodiment, the antibody binds to C5 at pH 7.4 and 25° C. (and, otherwise, under physiologic conditions) with an affinity dissociation constant (KD) that is at least 0.1 (e.g., at least 0.15, 0.175, 0.2, 0.25, 0.275, 0.3, 0.325, 0.35, 0.375, 0.4, 0.425, 0.45, 0.475, 0.5, 0.525, 0.55, 0.575, 0.6, 0.625, 0.65, 0.675, 0.7, 0.725, 0.75, 0.775, 0.8, 0.825, 0.85, 0.875, 0.9, 0.925, 0.95 or 0.975) nM. In some embodiments, the KD of the anti-C5 antibody, or antigen binding fragment thereof, is no greater than 1 (e.g., no greater than 0.9, 0.8, 0.7, 0.6, 0.5, 0.4, 0.3 or 0.2) nM.
In other embodiments, the [(KD of the antibody for C5 at pH 6.0 at 25° C.)/(KD of the antibody for C5 at pH 7.4 at 25° C.)] is greater than 21 (e.g., greater than 22, 23, 24, 25, 26, 27, 28, 29, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300, 350, 400, 450, 500, 600, 700, 800, 900, 1000, 1500, 2000, 2500, 3000, 3500, 4000, 4500, 5000, 5500, 6000, 6500, 7000, 7500 or 8000).
In various embodiments, eculizumab, an eculizumab variant such as BNJ441 (ravulizumab), 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).
In other embodiments, a patient switches from receiving one C5 inhibitor to a different C5 inhibitor during the course of treatment. Different anti-C5 antibodies may be administered during separate treatment periods. For example, in one embodiment, a method of treating a human patient having a complement-associated disorder (e.g., generalized myasthenia gravis (gMG)) who is being treated with eculizumab is provided, the method comprising discontinuing treatment with eculizumab and switching the patient to treatment with an alternative complement inhibitor. For example, in one embodiment, the patient is treated with eculizumab during a treatment period (e.g., for 26 weeks), followed by treatment with another anti-C5 antibody (e.g., ravulizumab) during an extension period. In one embodiment, eculizumab is administered to the patient at a dose of 900 mg on Days 1, 8, 15, and 22 of the administration cycle during an induction phase, followed by a maintenance dose of 1200 mg of eculizumab on Day 19 of the administration cycle and every two weeks thereafter (e.g., for a total of 26 weeks), followed by treatment with ravulizumab for an extension period of up to two years.
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.
In some embodiments, 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.
In some embodiments, 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.
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.
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.
As used herein, the term “bulbar signs” or “bulbar symptoms” refers to symptoms associated with bulbar weakness. These bulbar signs can include, but are not limited to, symptoms such as difficulty with speech (dysarthria), difficulty chewing, difficulty swallowing (dysphagia), and control of the head. In some embodiments, a bulbar sign is the onset of dysarthria. In some embodiments, the bulbar sign is difficulty swallowing. In some embodiments, the bulbar sign is difficulty chewing. In some embodiments, the bulbar sign is the onset of dysarthria, difficulty chewing, difficulty swallowing, and/or any combination thereof.
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.
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.
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.
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.
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.
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.
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 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.
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 is 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.
indicates data missing or illegible when filed
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-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 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.
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-QOL Fatigue score would be reflected in a decrease in score after 26 weeks of treatment.
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
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.
The MG clinical state is assessed using the MGFA Post-Intervention Status (see Table 6). Change in status categories of Improved, Unchanged, Worse, Exacerbation and Died of MG as well as the Minimal Manifestation (MM) can be assessed. Patients are considered to have achieved MM if they have no symptoms indicating functional limitations.
In some embodiments, the patient is treated and achieves the status of Improved or MM according to the MGFA Post-Intervention Status. In some embodiments, the patient achieves a status of improved or MM after being treated for 26 or 52 weeks. In some embodiments, the patient achieves a status of improved or MM after being treated for 4, 12, 66, 78, 104, 130, 156, or more weeks. In some embodiments, the patient is administered eculizumab in any manner as described herein. In some embodiments, the patient maintains an Improved or MM status by continuing treatment with eculizumab for 4, 12, 26, 52, 66, 78, 104, 130, 156, or more weeks. In some embodiments, the treatment comprises administering eculizumab 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, 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.
In some embodiments, the patient with MG or refractory MG achieves an Improved or MM score and seeks to maintain this score. In some embodiments, the patient is administered eculizumab in any manner as described herein. In some embodiments, the patient maintains an Improved or MM status by continuing treatment with eculizumab for 4, 12, 26, 52, 66, 78, 104, 130, 156, or more weeks. In some embodiments, the treatment comprises administering eculizumab 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, 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. In some embodiments, patients maintain an Improved status when they maintain a status of Improved or MM for a certain period.
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.
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.
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.
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.
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.
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.
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.
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.
In one particular embodiment, the eculizumab induction phase dosing regimen comprises five administered doses on the following schedule:
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.
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.
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.
In certain embodiments, the ravulizumab 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/plasmapheresis (PE/PP) and/or dosing with IVIg. In this phase after plasma is exchanged a dose of ravulizumab is administered to replace the drug lost in plasma exchange/plasmapheresis. According to certain embodiments, supplemental study drug (or placebo) dosing is required if PE/PP or IVIg rescue therapy is provided on nondosing days. In another embodiment, if PE/PP or IVIg infusion is provided on a dosing day, it must occur prior to study drug administration. According to certain embodiments, if PE/PP or IVIg is administered on nonscheduled dosing visits, patients receiving PE/PP will be administered a supplemental dose 4 hours after the PE/PP session is completed. In another embodiment, patients receiving IVIg will be administered a supplemental dose 4 hours after the last continuous session(s) of IVIg is completed. In certain embodiments, supplemental dose amounts may or may not vary depending on PE/PP or IVIg. In other embodiments, if PE/PP or IVIg is administered on scheduled dosing visits, regular dosing will be followed 60 minutes after the completion of PE/PP or IVIg. In certain embodiments, no gap is required between a supplemental dose and the regular scheduled dose.
In some embodiments, a loading dose of the anti-C5 antibody is administered intravenously at 1000 mg for patients between 40 kg and 100 kg (inclusive) or a loading dose of 1500 mg for patients >100 kg on week 1 day 1. In some embodiments, the anti-C5 antibody is administered on week 1, day 2, at a subcutaneous dose of 340 mg. In some embodiments, the anti-C5 antibody is administered on week 2, week 3, and week 4 at a subcutaneous dose of 340 mg. In some embodiments, the anti-C5 antibody is administered on week 5 at a subcutaneous dose of 680 mg for patients between 40 kg and 100 kg (inclusive) or a subcutaneous dose of 1020 mg for patients >100 kg, followed by a subcutaneous dose of 680 mg for patients between 40 kg and 100 kg (inclusive) or a subcutaneous dose of 1020 mg for patients >100 kg every 4 weeks. In some embodiments, the anti-c5 antibody is administered for 24 weeks. In some embodiments, the anti-C5 antibody used with this dosing regimen is crovalimab (SKY59/RG6107).
In one embodiment, the anti-C5 dosing regimen comprises doses on the following schedule:
administration intravenously at 1000 mg for patients between 40 kg and 100 kg (inclusive) or a loading dose of 1500 mg for patients >100 kg on day 1; administration subcutaneously at a dose of 340 mg on day 2 (week 1); administration subcutaneously at a dose of 340 mg on week 2, administration subcutaneously at a dose of 340 mg on week 3, administration subcutaneously at a dose of 340 mg on week 4, administration subcutaneously at a dose of 680 mg for patients between 40 kg and 100 kg (inclusive) or 1020 mg for patients >100 kg on week 5, and then administration subcutaneously at a dose of 680 mg for patients between 40 kg and 100 kg (inclusive) or 1020 mg for patients >100 kg every 4 weeks thereafter. The actual days between each dose may vary by 1 or 2 days to accommodate unexpected events in the patients' schedule.
In some embodiments, a loading dose of the anti-C5 antibody is administered intravenously at a dose of 30 mg/kg, followed by a once weekly dose of 800 mg administered subcutaneously. In some embodiments, the anti-C5 antibody used with this dosing regimen is pozelimab.
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.
An exemplary, non-limiting range for a therapeutically or prophylactically effective amount of eculizumab or other anti-C5 antibodies such as BNJ441 (ravulizumab), 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.
Also provided are pharmaceutical compositions comprising other anti-C5 antibodies, either alone or in combination with prophylactic agents, therapeutic agents, and/or pharmaceutically acceptable carriers. In some embodiments, a non-limiting range for a therapeutically or prophylactically effective amount of crovalimab is 1000 mg for patients between 40 kg and 100 kg (inclusive) or 1500 mg for patients >100 kg. In some embodiments, a non-limiting range for a therapeutically or prophylactically effective amount of crovalimab is 340 mg. In some embodiments, a non-limiting range for a therapeutically or prophylactically effective amount of crovalimab is 680 mg for patients between 40 kg and 100 kg (inclusive) or 1020 mg for patients >100 kg. In some embodiments, a non-limiting range for a therapeutically or prophylactically effective amount of pozelimab is 30 mg/kg. In some embodiments, a non-limiting range for a therapeutically or prophylactically effective amount of pozelimab is 800 mg.
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.
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], cyclosporine, and/or mycophenolate mofetil [MMF]).
Without limiting the disclosure, a number of embodiments of the disclosure are described below for purpose of illustration.
Table 7 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 7 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 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
The antibody may be an eculizumab variant known as BNJ441, also known as ravulizumab, and having selected mutations in the CDR regions combined with mutations in the Fc region to increase the T½ 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
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 7 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.
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 7 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.
The anti C5 antibody can comprise, for example, the heavy and light chain CDRs or variable regions of the 305LO5 antibody. The anti C5 antibody can comprise, for example, heavy chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs: 37, 38 and 39, respectively, and light chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs: 40, 41 and 42, respectively. In another embodiment, the antibody comprises the VH region of the 305LO5 antibody having the sequence set forth in SEQ ID NO: 43, and the VL region of the 305LO5 antibody having the sequence set forth in SEQ ID NO: 44.
The anti-C5 antibody can comprise, for example, the heavy and light chain CDRs or variable regions of the SKY59 antibody. The anti C5 antibody can comprise, for example, a heavy chain comprising SEQ ID NO:45 and a light chain comprising SEQ ID NO:46.
The anti-C5 antibody can comprise, for example, the REGN3918 antibody (also known as H4H12166PP). The anti C5 antibody can comprise, for example, a heavy chain variable region comprising SEQ ID NO:47 and a light chain variable region comprising SEQ ID NO:48, or a heavy chain comprising SEQ ID NO:49 and a light chain comprising SEQ ID NO:50.
The antibody may also be an anti-C5 antibody or antigen binding fragment thereof comprising a heavy chain variable region amino acid sequence according to SEQ ID NO: 51 and a light chain variable region amino acid sequence according to SEQ ID NO: 52.
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The primary objective of this trial was 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).
The secondary objectives of this trial included the following:
Described herein is a randomized, double-blind, parallel-group, placebo-controlled, multicenter (˜100 sites in North America, South America, Europe, Asian Pacific) approximately two year trial that evaluated the safety and efficacy of eculizumab for the treatment in subjects with refractory gMG. Approximately 92 eligible subjects were randomized on Day 1 on a 1:1 ratio to one of two treatment arms (1) eculizumab infusion or (2) placebo infusion. Subjects continued to receive stable dose/type of immunosuppressive therapy (IST), but no new ISTs and no increase in IST dosage were permitted during the trial. There were 3 periods in this study: Screening Period, Study Period, and Follow-up Period (for subjects who withdrew from this trial or who did not enter the extension trial). See
At the screening visit, after obtaining the informed consent from the subject, the subject was 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.
If all inclusion criteria and none of the exclusion criteria were met, subjects were 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 were vaccinated at least 14 days prior to receiving the first dose of study medication were vaccinated and received treatment with appropriate antibiotics until 14 days after the vaccination. See
Use of cholinesterase inhibitor and supportive IST were allowed during the trial under certain restrictions (see Concomitant Medications, below). The washout period for IVIg was 4 weeks prior to randomization. The washout period for PE was also 4 weeks prior to randomization. If a subject experienced an MG Crisis during the Screening Period, the sponsor was notified. Following discussion with the sponsor, a decision was made about whether the subject may continue in the trial, be withdrawn and possibly, re-screened at a later date.
N. meningitidis
N. meningitidis
All subjects who were vaccinated, and continued to meet the MG-ADL entry criteria, i.e., MG-ADL total score ≥6 at Randomization (Day 1), and were cleared for randomization by their respective Principal Investigator (PI), were 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 9) performed at the Screening Visit according to the following 4 groupings:
Subjects received 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 was 26-weeks. Subjects were informed of potential signs and symptoms of MG crisis and were instructed to contact the Investigator as soon as possible at onset of symptom. Every effort was 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 performed the assessments as specified by this protocol. The Investigator determined whether or not the subject met the definition of Clinical Deterioration as defined by this protocol and treated the subject accordingly.
After completing the 26-week Study Period, subjects were 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 was 2 weeks from the last of IP administration (Visit 17) so there was no interruption in IP dosing. Subjects that entered the extension trial underwent 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 withdrew from this trial at any time after receiving any amount of IP or did not wish to enter the extension trial after completion of this trial, the subject was required to complete the Follow-up Visit for safety measures.
If a subject withdrew or is discontinued from this trial at any time after receiving any amount of IP or did not wish to enter the extension trial after completion of this trial, the subject was 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 was followed until it was resolved or in the opinion of the PI was medically stable.
Abbreviations and definitions for the study and follow-up period are provided in Table 10.
For this protocol. Clinical Deterioration was defined as follows:
The Clinical Evaluators were study staff that have been trained and certified in administering the MG-ADL, QMG and MGC. The Clinical Evaluator may have been a neurologist, physical therapist or other study team member delegated by the PI. Clinical Evaluator training and certification for this protocol took place either at the Investigator's meeting or via the sponsor's designated on-line training portal.1.2.3.
Responsibilities for MG Assessments
Responsibilities for MG assessments are listed in Table 11. Throughout the trial, MG assessments were performed at approximately the same time of day by a properly trained evaluator, preferably the same evaluator.
(Days −28 to −14 Prior to Baseline [Visit 2/Day 1])
After obtaining a signed informed consent form, the following tests and evaluations were 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:
Visit intervals during Induction Phase (Visits 2, 3, 4, 5 and 6) were weekly (every 7 f 2 days after the last visit). Visit intervals during the Maintenance Phase (Visits 7-17) were every 2 weeks (every 14 days±2 days since the last visit). Subjects who fail to return for a scheduled visit were contacted by the site study staffs to determine the reason for missing the appointment. Subjects were strongly encouraged to return to the investigational site for evaluation if Clinical Deterioration or an AE was suspected to have occurred. In the exceptional circumstance where a subject could not or did not come to the study site for examination, then the subject was instructed to see his or her local neurologist or physician. In this event, the investigational site obtained relevant medical records as documentation from the local physician's examination, and entered relevant data in the eCRF as appropriate.
As it was 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 was made to undertake protocol-specified follow-up procedures (see Table 8). Follow-up due diligence documentation consisted of 3 phone calls followed by 1 registered letter to the subject's last known address. The study period is summarized in Table 8 and
Once all of the eligibility criteria were confirmed by the P1, the subject was randomized on Day 1. The following tests and procedures were completed at the Baseline Visit (Visit 2/Day 1):
The following tests and procedures are completed:
The following tests and procedures are completed at this visit:
During the Maintenance Phase, subjects returned for infusions of IP every 2 weeks (14±2 days), according to the regimen described in Section 4.5. The following tests and procedures were completed at every visit beginning at Visit 7 (Week 6) and continued until the End of Study (EOS), Visit 17 (Week 26) or at Early Termination (ET):
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 were also completed, in addition to the 5 preceding procedures listed for the maintenance phase:
The evaluation visit for an MG crisis or Clinical Deterioration was performed as soon as possible, within 48 hours of notification of the Investigator of the symptom onset. Additional evaluation visits were scheduled at the discretion of the investigator. The following tests and procedures were completed at this visit:
Additional (Unscheduled) visits outside the specified visits were permitted at the discretion of the Investigator. Procedures, tests, and assessments were performed at the discretion of the Investigator. If an Unscheduled Visit was performed, any tests, procedures, or assessments performed at the Unscheduled Visits were recorded on the eCRFs.
If a subject withdrew from the trial at any time during the Study Period after receiving any amount of IP (eculizumab or placebo) or did not wish to enter the extension trial after completion of this trial, a follow up visit for safety assessment was required at 4 weeks after the last dose of IP. The following tests and procedures were completed at the safety follow-up visit:
If a subject discontinued due to an AE, the AE was followed until it was resolved or, in the opinion of the PI, was determined medically stable.
126 subjects with refractory gMG were randomized in a 1:1 (eculizumab: placebo) ratio at approximately 100 centers. Randomization was across centers and was stratified based on MGFA clinical classifications (Class a vs. Class b and Classes II and II vs. Class IV) (see Table 8).
126 subjects with refractory gMG are randomized, 63 subjects to eculizumab and 63 subjects to placebo. All patients remained on assigned double-blind treatment until the EOS/ET visit. Randomized subjects who discontinued after initiation of study treatment were not replaced. Assignment was performed through the IXRS at each visit.
2.3.1. Withdrawal of Subjects from the Trial
Subjects were allowed to withdraw consent at any time. Every effort was made to ensure subjects were willing to comply with trial participation prior to conducting the screening procedures and the subjects were fully informed of the restrictions related to the change of concomitant medications during the trial. Investigators may have chosen 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 notified the Sponsor and their site monitor of all trial withdrawals as soon as possible.
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 continued to use adequate contraception for up to 5 months following discontinuation of eculizumab treatment. If a subject became pregnant, the IP was immediately discontinued and the Sponsor was notified. Each pregnancy was followed to term and the Sponsor notified regarding the outcome.
When a subject withdrew or was withdrawn from the trial, the Investigator recorded the withdrawal reason(s). Whenever possible, all subjects who prematurely withdrew from the trial underwent all assessments at the ET visit for safety as per the Schedule of Assessments (Table 8). A follow-up visit for safety assessment was required at 8 weeks after the last dose of IP administration (Table 8).
If a subject discontinued due to an AE, the event was followed until it was resolved or in the opinion of the PI the subject is determined to be medically stable. Every effort was made to undertake protocol-specified safety follow-up procedures.
Subjects who failed to return for final assessments were contacted by the site study staffs in an attempt to have them comply with the protocol. As it was vital to obtain follow-up data on any subject withdrawn because of an AE or SAE, follow-up due diligence documentation consisted of 3 phone calls followed by 1 registered letter to the subject's last known address. In any case, every effort was made to undertake protocol-specified safety follow-up procedures.
Alexion Pharmaceuticals, Inc. or a regulatory authority may have discontinued the trial at any time for any reason including, for example, clinical or administrative reasons.
The end of trial is defined as the last visit completed by the last patient.
Eculizumab (600 mg, 900 mg or 1200 mg) or matching placebo was administered intravenously over approximately 35 minutes according to the regimen shown in Table 13.
Induction Phase
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).
Maintenance Phase
Eculizumab or placebo: 4 vials of IP (equivalent to 1200 mg of eculizumab) every 2 weeks (14 days±2 days)
Supplemental Doses
If PE was administered due to a Clinical Deterioration (as defined by this protocol), supplemental IP (2 vials, equivalent to 600 mg of eculizumab or matching placebo) was administered within 60 minutes after the end of each PE session. If PE was administered on a day of regularly scheduled IP administration, subjects received 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.
Palliative and supportive care was permitted during the course of the trial for underlying conditions.
The following medications were allowed under certain circumstances and restrictions.
The following immunosuppressive agents were 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 was at the discretion of the treating physician.
Use of PE or IVIg was allowed for subjects who experience a Clinical Deterioration as defined by this protocol. The rescue therapy used for a particular subject was at the discretion of the treating physician. Every effort should was to notify the Sponsor within 24 hours should a subject require a rescue therapy.
If PE was administered as a rescue therapy, supplemental IP (2 vials) were administered within 60 minutes after the end of each PE session. Routine (per protocol schedule) IP administration was continued per the specified dose-administration schedule for the subject. If the subject was scheduled to receive the protocol-scheduled dose on the day of a PE session, then the scheduled dose was administered within 60 minutes after the end of the PE session.
The following concurrent medications were prohibited during the trial:
The infusion of IP into subjects was under the supervision of the PT/Sub-Investigator or their designee, to ensure that the subject received the appropriate dose at the appropriate time-points during the trial.
Subjects who failed to return for a scheduled visit within the accepted intervals were 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.
Subjects were randomized on Day 1 after the Investigator verified that they are eligible. Subjects were 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:
All trial subjects, investigational site personnel, sponsor staff, sponsor designees, and all staff directly associated with the conduct of the trial were blinded to the subject treatment assignments. The double blind is maintained by using identical IP kits and labels for eculizumab and placebo. The placebo had an identical appearance to that of eculizumab. The random code was maintained by Almac Clinical Services. There is no antidote to reverse the effects of eculizumab.
Therefore, unblinding would not be helpful in the planning of patient treatment for a given event. Unblinding was only considered for the safety of the subject. If unblinding was deemed necessary by the Investigator, the Investigator could have unblinded the patient's treatment allocation using IXRS. The Investigator must have noted the date, time and reason for unblinding.
The Investigator should have informed the Medical Monitor that the patient was unblinded, however they are not required to reveal to the Medical Monitor the patients' treatment allocation.
When an AE was an unexpected related serious AE, the blind was broken by the Sponsor only for that specific subject. The blind was 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 was only accessible to those who need to be involved in the safety reporting to Health Authorities, Ethics Committees and/or IRBs.
Investigators received only blinded information unless unblinded information is judged necessary for safety reasons.
Each vial of IP contains eculizumab 300 mg or matching placebo for IV administration.
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 14.
All study medication was prepared in vials, packaged in kits, labeled in an identical manner.
IP vials were individually packaged into a kit. Both vials and kits were labeled according to the protocol and local regulatory requirements. Each kit had a label describing the contents and a place for the pharmacist to record the subject number and initials.
Study medication was shipped and released to each participating trial center upon receipt of all required essential documents based upon federal, state, and local regulations (Table 14).
IP was released to the site upon receipt of all required essential documents based upon federal, state, and local regulations. See Table 14.
Upon arrival at the center, the IP was promptly removed from the shipping cooler and stored in refrigerated conditions at 2 to 8° C. The pharmacist immediately recorded the reception of the IP and notified the distributor if vials were damaged and/or if temperature excursions occurred during transportation. IP was stored in a secure, limited-access storage area and temperature was monitored daily.
Diluted solutions of IP were stored at 2 to 8° C. (36-46° 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 was stored at 2 to 8° C. The solution was allowed to warm to room temperature prior to administration. The material was not heated (e.g., by using a microwave or other heat source) other than by ambient air temperature.
Infusions of IP were prepared using aseptic technique. Each vial of IP contained 300 mg of active ingredient in 30 mL of product solution or matching placebo.
The required amount of IP was withdrawn from the vials. The recommended dose was transferred to an infusion bag. The IP was diluted 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 15.
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
The infusion bag containing the diluted IP solution was gently inverted to ensure thorough mixing of the product and diluents. Any unused portion left in a vial was discarded, as the product contains no preservatives. The diluted solution was allowed to warm to room temperature by exposure to ambient air prior to administration.
Do not Administer as an IV Push or Bolus Injection
IP was only administered via IV infusion and was diluted to a final concentration of 5 mg/mL prior to administration. Prior to administration, if the diluted solution was refrigerated, it was allowed to warm to room temperature by exposure to ambient air. The diluted solution was not heated in a microwave or with any heat source other than ambient air temperature. Parenteral drug products were inspected visually for particulate matter and discoloration prior to administration.
The diluted IP was intravenously administered over 35 minutes (range 25 to 45 minutes). It was not necessary to protect the infusion bags from light while IP was being administered to the subject. At the site's discretion, the diluted IP was administered via gravity feed, a syringe-type pump, or an infusion pump. The subjects were monitored for 1 hour following infusion.
If an AE occurred during the administration of the IP, the infusion was slowed or stopped at the discretion of the Investigator, depending upon the nature and severity of the event. The overall time of infusion did not exceed 2 hours. The AE must be captured in the subject's source document and CRF.
Duration of treatment commenced with the first infusion of IP (eculizumab or placebo). The 26-week Study Period defined the time period for assessment of the study endpoints (specified in Table 8, the schedule of assessments). Efficacy was 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.
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 was performed at Screening, Day 1, Weeks 1-4, 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.
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 was 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
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 was 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).
The 15-item Myasthenia Gravis Qualify of Life scale (MG-QOL 15) (see
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-QOL Fatigue score would be reflected in a decrease in score after 26 weeks of treatment. The Neuro-QOL Fatigue was 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).
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
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 was 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).
The MG clinical state is assessed using the MGFA Post-Intervention Status. See Table 6. Change in status categories of Improved, Unchanged, Worse, Exacerbation and Died of MG as well as the Minimal manifestation (MM) was 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.
The study design was a randomized, double blind, placebo-controlled design. Subjects were randomly assigned 1:1 to eculizumab or placebo. The randomization stratification variable was 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).
The sample size and power calculation assumptions are as follows:
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.
Analyses were 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.
The full analysis set (FAS) was 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 were compared for efficacy according to the treatment they were randomized to receive, irrespective of the treatment they actually received.
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 included all subjects who:
Note: During the Study Period, Baseline is defined as the last available assessment prior to treatment for all subjects, regardless of treatment group.
The primary efficacy endpoint was change from baseline in the MG-ADL total score at Week 26 of the Study Period. The primary efficacy analysis was conducted on the available 26 week data from the Study Period for all subjects. The trial was considered to have met its primary efficacy objective if a statistically significant difference (p≤0.05) between the eculizumab treatment group and placebo group was observed for change from baseline in the MG-ADL total score at Week 26. Confidence intervals and p-values are presented. For the primary analysis concerning the change from baseline in the MG-ADL total score at Week 26, treatment groups were 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 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 is 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.
A sensitivity analysis for the actual change from baseline in the MG-ADL total score at Week 26 was 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 were also covariates in the model. Last observation carried-forward is used for missing changes from baseline at Week 26.
A sensitivity analysis for the actual change from baseline in the MG-ADL total score at Week 26 was also performed. In the sensitivity analysis, treatment groups were 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 were also covariates in the model. Subjects have an IST treatment status variable defined based on the IST treatments the subject receives.
In addition, summaries of changes from baseline in the MG-ADL total score at Week 26 were produced by treatment group for subjects who have failed ISTs.
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 were performed using a closed testing procedure with the following rank order:
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≤0.05), then endpoints of lower rank were not considered to be statistically significant. Confidence intervals and p-values were presented for all secondary efficacy endpoints for descriptive purposes, regardless of the outcome of the closed testing procedure.
The secondary endpoints that involve changes from baseline were 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.
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 was also a covariate in the model. A sensitivity analysis for the actual change from baseline in QMG score at Week 26 was performed. Treatment groups were 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.
A sensitivity analysis for the change from baseline in MGC at Week 26 was 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.
A sensitivity analysis for the change from baseline in MG-QOL-15 at Week 26 was 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 was also a covariate in the model.
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.
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 was analyzed by the Cochran-Mantel-Haenszel test stratified by randomization stratification variable in order to compare eculizumab versus placebo.
Additional sensitivity analyses were performed in order to 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.
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.
The tertiary efficacy analyses for the Study Period included the following:
For the time to response on the MG-ADL total score (3-point reduction in MG-ADL from baseline), treatment groups were compared using Cox PH regression with robust variance estimation. The randomization stratification variable was also a covariate in the model. Inference was based on the Wald test of the log hazard ratio.
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).
The tertiary endpoints that involved 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.
A sensitivity analysis for the change from baseline in NIF at Week 26 for subjects with abnormal NIF at baseline was analyzed using repeated measures model with effects for treatment, visits, and baseline NIF in order to compare treatment groups. The randomization stratification variables were also covariates in the model.
A sensitivity analysis for the change from baseline in FVC was analyzed using repeated measures model with effects for treatment, visits, and baseline FVC in order to compare treatment groups. The randomization stratification variable was also a covariate in the model.
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 were 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 were 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.
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 was produced.
For all analyses, the eculizumab treated group was 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
For efficacy and safety analyses, missing post-baseline efficacy and safety data were not imputed unless indicated in the described analysis in the SAP.
There is no interim analysis planned for this trial.
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 included:
The extension trial lasted for 4 years (FPFV to LPLV). The first visit occurred within 2 weeks of Visit 17 (Week 26) in the trial described above. To maintain the blind of the previous trial, all subjects underwent a blind induction phase, followed by an open label maintenance phase. This is summarized in
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.
Efficacy was measured by MG-ADL, QMG, MGC, NIF, FVC, QOL, G-QOL15, Neuro-QOL Fatigue, EQ-5D and MGFA Post-Intervention Status.
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 ≥6 at study entry.
As discussed above the patients were initially randomized according to MGFA Clinical Classification shown in Table 9 into the following four groups:
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.
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.
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.
The disposition of patients completing the 301 trial and entering the 302 trial is shown below in Table 16.
Therefore 96.8% of the placebo patients and 88.9% of the eculizumab patients proceeded into the extension trial.
The demographics of the 301 trial participants were as is shown below in Table 17.
The protocol defines clinical deterioration as a subject who has one of the following:
1. MG Crisis
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):
3. The treating physician believes that the subject's health is in jeopardy if rescue therapy is not administered.
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
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.
The total numbers of patients who experienced clinical deterioration during the protocol were as is shown below in Table 18.
The clinical deteriorations requiring rescue therapy are shown in Table 19 below:
The primary and secondary endpoints as described above were used as shown below:
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.
The results from the patients who finished the entire protocol are shown in Table 20. Therefore, as shown in Table 22 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.
The data were analyzed in multiple ways for statistical purposes as shown in Tables 20, 21, 22, and 23, 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 20-23.
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.
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.
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 24 below and
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.
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 25 above for the results.
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 MG-QOL would be a decrease in score after 26 weeks of treatment.
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 26 below for the results.
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-QOL Fatigue score would be reflected in a decrease in score after 26 weeks of treatment.
As shown in Table 27 below, the eculizumab treated group realized a clinically meaningful improvement (reduction) in their Neuro-QOL Fatigue score after 26 weeks of treatment.
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.
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.
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.
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
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 during the ECU-MG-301 REGAIN Trial (see Example 1 for protocol). 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) (
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 ≥3-point improvement in MG-ADL total score with no rescue; and the proportion of patients with ≥5-point improvement in QMG total score with no rescue. In an ad hoc dual responder analysis, response was defined as an improvement of ≥3 points from baseline in the MG-ADL total score and improvement of ≥5 points from baseline in the QMG total score, with no rescue therapy. In addition to the prespecified responder thresholds (i.e., 3-point improvement for MG-ADL and ≥5-point improvement for QMG), thresholds of ≥4, 5, 6, 7, and 8 for MG-ADL and ≥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.
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 (
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.
As shown in
Patients who completed REGAIN were allowed to continue into an open-label extension study known as ECU-MG-302 (see Example 2 for protocol). 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.
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 for up to 4 years). MG-ADL, QMG, MGC, and MG-QOL15 scores and safety were assessed. Patients entering the ECU-MG-302 open-label study had baseline MG-ADL total scores of 5.8 (standard deviation, 4.27) for the eculizumab/eculizumab group, and 7.6 (standard deviation 3.63) for the placebo/eculizumab group.
The MG-ADL total score in eculizumab/eculizumab patients (n=55) was unchanged (0.2 point reduction; standard deviation 1.77) from open-label baseline through week 4 of the blind induction phase. The MG-ADL total score in this group of patients remained unchanged (standard deviation 3.97) from open-label baseline through week 52 of the ECU-MG-302 open-label-study. These patients had a 4.5 point mean reduction (standard deviation 3.96) in MG-ADL total score from REGAIN baseline measurements. A total of 35 eculizumab/eculizumab patients completed 130 weeks of the ECU-MG-302 open-label study and were measured for MG-ADL score. The MG-ADL score in this group of patients was slightly improved (0.7 point reduction; standard deviation 4.19) from open-label baseline.
In the placebo/eculizumab patients (n=61), 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 point reduction [−2.28, −0.89]; p<0.0001). The majority of the overall treatment effect was achieved by week 4 (2.4 point reduction [−3.19, −1.71]; p<0.000l) during the blind induction phase, and was sustained through week 52 (2.7 point reduction [−3.73, −1.63]; p<0.0001). This group of patients demonstrated a 5.0 point mean reduction (standard deviation 3.39) in MG-ADL total score from REGAIN baseline measurements. A total of 36 placebo/eculizumab patients completed 130 weeks of the ECU-MG-302 open-label study and were measured for MG-ADL score. The MG-ADL score in this group of patients was improved (3.9 point reduction; standard deviation, 3.68) from open-label baseline.
Changes in QMG, MGC, and MG-QOL 15 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.
Overall, 65 (55.6%) patients reported a change in their IST usage during the study. Greater proportions of patients had dose reductions or stopped ≥1 IST than those who had dose increases or started ≥1 IST (Table 28). 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.
Overall, the extension study demonstrated that patients who received eculizumab in Study ECU-MG-301 sustained their improvements through the 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 the Study ECU-MG-302, similar to the effect observed in eculizumab-treated patients in Study ECU-MG-301.
This example provides a detailed evaluation of patients' response to eculizumab treatment during REGAIN (ECU-MG-301 REGAIN; see Example 1 for protocol) and up to week 130 of an open-label extension (OLE) study ECU-MG-302; see Example 2 for protocol. The 6-month, phase 3, randomized, placebo-controlled REGAIN study demonstrated the efficacy and safety of eculizumab in patients with anti-AChR antibody-positive (AChR+) refractory gMG. An interim analysis of results of the open-label extension of REGAIN found that the benefits of eculizumab for this patient population were maintained through 3 years of treatment. At the last assessment before Dec. 31, 2017 (the data cut-off date for the interim analysis), 74.1% of patients had an MGFA post-intervention status of improved, and 56.0% were considered to have achieved MM or PR. Here, we report a detailed evaluation of patients' response to eculizumab treatment during REGAIN and up to week 130 of the open-label study using MGFA post-intervention status.
Patients who completed REGAIN (ClinicalTrials.gov identifier: NCT01997229) were eligible for inclusion in an open-label study (ClinicalTrials.gov identifier: NCT02301624) and were required to enroll within 2 weeks of completing REGAIN. Patients were eligible for inclusion in REGAIN if they had confirmed gMG, AChR+serology, a Myasthenia Gravis Activities of Daily Living (MG-ADL) total score of at least 6, and had received two or more ISTs, or at least one IST with intravenous immunoglobulin or plasma exchange treatment at least four times in 12 months without symptom control. Patients with ocular MG (MGFA class I) or myasthenic crisis at screening (MGFA class V) were excluded from the trial. Full eligibility criteria have been published previously. All participants were required to have been vaccinated against Neisseria meningitidis at least 2 weeks before starting study treatment; individuals who were not vaccinated at the appropriate time received prophylactic antibiotics until 2 weeks after vaccination. During the open-label study, patients were revaccinated according to local guidelines. During REGAIN, patients who previously received ISTs were required to maintain their pre-study dose and schedule. During the open-label study, modifications to IST dose and schedule were permitted at the discretion of the investigator; however, changes were not required by the protocol.
All patients provided written, informed consent. Independent ethics committees or institutional review boards provided written approval for the study protocols and all amendments. The studies were performed in accordance with the ethical standard laid down in the 1964 Declaration of Helsinki and are registered with www.clinicaltrials.gov.
In REGAIN, patients randomized to receive eculizumab were given an induction dose of 900 mg on day 1 and at weeks 1, 2 and 3, followed by a maintenance dose of 1200 mg at week 4 and every 2 weeks thereafter (
The objectives of REGAIN and the open-label study were to assess the efficacy of eculizumab, as measured by change in MG-ADL total score from baseline, and to evaluate its safety. This secondary analysis assessed MGFA post-intervention status and safety data during REGAIN and the open-label study for patients who continued into the open-label study.
MGFA post-intervention status following administration of eculizumab or placebo during REGAIN, including achievement of MM, was assessed at weeks 4, 12 and 26 of REGAIN and weeks 26, 40, 52 and 130 of the open-label study. MGFA post-intervention status was reported as improved if a patient's pretreatment clinical manifestations were substantially decreased, worse if they were substantially increased, or unchanged if they were not substantially changed compared with REGAIN baseline. In patients with improved status, MM was achieved if they had no symptoms indicating functional limitations from MG but had some weakness on examination of some muscles. Subcategories of MM relating to treatment status were not assessed. Patients were evaluated for PR at open-label study weeks 26, 40, 52 and 130. PR was achieved if patients had no signs or symptoms of MG for at least 1 year and, upon examination, had no weakness of any muscle, other than isolated weakness of eyelid closure.
Adverse events were recorded and coded by preferred term using the Medical Dictionary for Regulatory Activities Version 20.1. MG exacerbations, use of rescue therapy and study discontinuations because of adverse events were also recorded.
Common odds ratios for achievement of improved status or MM at REGAIN week 26 for patients who received eculizumab compared with those who received placebo were calculated using an ordinal regression model.
Results
A total of 117 patients who completed REGAIN continued into the open-label study (eculizumab/eculizumab, 56; placebo/eculizumab, 61.
During REGAIN, at all time points assessed, a higher proportion of patients who received eculizumab than of those who were given placebo achieved improved status (Table 29,
During REGAIN, the proportion of patients receiving eculizumab who achieved MM increased from 18.2% (10/55) at week 4 to 25.0% (14/56) at week 26 (Table 29,
Patients in the eculizumab/eculizumab and placebo/eculizumab groups received eculizumab for different periods of time during REGAIN and its open-label extension; of all patients who received eculizumab for 26 weeks (eculizumab/eculizumab group to week 26 of REGAIN and placebo/eculizumab group to week 26 of the open-label study), most (66.1%; 74/112) achieved improved status and over one-third (36.6%; 41/112) achieved MM status (Table 30). Almost one-third of participants (32.1%; 36/112) had a status of unchanged and two patients had a status of worse after 26 weeks' eculizumab therapy (Table 30). The proportions of patients who achieved improved or MM status increased with continued eculizumab treatment: 88.0% (66/75) of those who received eculizumab for 130 weeks achieved improved status and 57.3% (43/75) achieved MM status (Table 30). In addition, two patients achieved PR after 130 weeks of eculizumab therapy.
There were no differences in mean age (46.5 versus 47.4 years; P=0.7919) or mean disease duration (9.3 versus 10.3 years; P=0.5334) between eculizumab-treated patients who achieved MM to open-label study week 130 (n=76) and those who did not (n=37). these groups
Safety
Safety data have previously been published for REGAIN and the interim analysis of the open-label study. Across these two studies, the most common adverse events with eculizumab for patients included in this analysis were headache and nasopharyngitis, which were experienced by 44.4% and 38.5% of patients, respectively (Table 31). Serious adverse events of worsening of MG and MG crisis occurred in 15.4% and 3.4% of patients, respectively. MG exacerbations were experienced by 29.1% of patients, and 25.6% used rescue therapy.
aPY is the sum of all years for all patients and the observed event rate is the number of events per PY multiplied by 100. B. Medical Dictionary for Regulatory Activities preferred term.
cIf a patient had more than one adverse event for a particular preferred term, that patient is counted only once for that preferred term.
dWorsening (increased frequency and/or intensity) of a preexisting condition, including myasthenia gravis, is considered to be an adverse event.
This analysis found that patients with AChR+refractory gMG treated with eculizumab experienced rapid improvements in their clinical condition based on MGFA post-intervention status. Over 50% of patients achieved a status of improved within 4 weeks of their first dose of eculizumab in REGAIN and one-third of these patients also achieved MM. By REGAIN week 26, significantly higher proportions of eculizumab-treated patients than placebo-treated patients achieved an MGFA post-intervention status of improved or MM.
Long-term eculizumab treatment was associated with further increases in the proportions of patients who achieved a status of improved or MM. After 130 weeks of eculizumab therapy, almost 90% of all patients had attained a status of improved and nearly 60% had achieved MM. These findings suggest that for some patients with AChR+refractory gMG, long-term treatment with eculizumab was required for optimal disease control. Furthermore, two patients achieved PR after 130 weeks of eculizumab treatment, reflecting long-term maintenance of symptom relief.
The long-term safety profile of eculizumab was consistent with its known profile from over 10 years of clinical use in other indications, and no new safety signals were observed during the open-label study.
The main limitation of this analysis was the open-label design of the extension study, which could yield unconscious bias in reporting. Because over 90% of patients who enrolled in REGAIN continued into the open-label study, selection bias in the open-label study population was unlikely.
In conclusion, the results of this example confirmed the rapid and sustained clinical response to eculizumab that was observed during REGAIN and the open-label study. Over 50% of patients who were considered to have refractory disease achieved the consensus treatment goal of MM or better after 1 year of eculizumab treatment. These findings further supported the long-term effectiveness of eculizumab for use in patients with AChR+refractory gMG.
IVIg is a proven short-term therapy for MG exacerbations/crises, and is also considered as a maintenance therapy in treatment-refractory MG inadequately controlled with standard IST. The longevity of its effects is limited, however, and there are some tolerability issues associated with chronic IVIg therapy. In this example, the response of patients recently treated with IVIg to eculizumab enrolled in the ECU-MG-301 REGAIN Trial (see Example 1 for protocol) and the Open-Label Extension (OLE) study (ECU-MG-302; see Example 2 for protocol) was analyzed.
The response to eculizumab was evaluated over a period of up to 18 months in patients receiving chronic intravenous immunoglobulin (IVIg) before participating in REGAIN. This subgroup comprised patients who had received IVIg at least four times in 1 year, with at least one IVIg treatment cycle during the 6 months before the first REGAIN study dose. Patients were excluded from REGAIN if they had received IVIg in the 4 weeks before randomization, and concomitant IVIg use was only permitted during REGAIN/OLE as rescue therapy. Response to eculizumab versus placebo was assessed using four validated, disease-specific measures. Incidence of exacerbations and safety endpoints were recorded.
Specifically, response was assessed using MG-ADL, QMG, MG Composite scale (MGC) and 15-item MG Quality of Life Questionnaire (MG-QOL15). A clinical response was defined as a ≥3-point improvement in MG-ADL total score or a ≥5-point improvement in QMG total score at the evaluation time point compared with REGAIN baseline. The incidence of exacerbations (defined as an MG crisis, significant symptomatic worsening or requirement for rescue therapy) was evaluated throughout REGAIN/OLE, and during the year before REGAIN enrollment. Safety endpoints were assessed throughout REGAIN/OLE.
Changes from REGAIN baseline in MG-ADL, QMG, MGC and MG-QOL15 mean total scores were based on t-tests. Data are presented as the mean change from REGAIN baseline; mean differences between treatment groups are presented as 95% confidence intervals (CIs). The responder analyses measured the proportion of patients with clinically meaningful improvements from REGAIN baseline. Exact (Clopper-Pearson) 95% CIs for the responder proportions are presented. For exacerbations, model-based event rates per 100 patient-years were calculated following previously published methodology. All statistical analyses were performed using SAS version 9.4.
A total number of 18 patients were included (eculizumab, n=9; placebo, n=9) in this analysis. One eculizumab-treated patient withdrew from REGAIN; 17 patients continued into the OLE (eculizumab/eculizumab, n=8; placebo/eculizumab, n=9). Baseline demographics and characteristics, including mean baseline scores for MG-ADL, QMG, MGC and MG-QOL15, were generally similar for both subgroup treatment arms and the overall REGAIN population. The duration between last recorded IVIg dose end date and first REGAIN study dose was 4-16 weeks (n=17; one patient missing accurate end-date data). In the year before entering REGAIN, 9/18 patients experienced at least one exacerbation (eculizumab: six events in four patients; placebo: 19 events in five patients); there was also one patient with MG crisis in the eculizumab group. Compared with the overall REGAIN population, this subgroup experienced a higher rate of exacerbations in the year before REGAIN start (150.0 vs 102.4 exacerbations/100 patient-years).
At REGAIN week 26, eculizumab-treated patients had numerically larger improvements from baseline in MG-ADL and QMG mean total scores than placebo-treated patients (Table 32). Improvements from baseline in MG-ADL, QMG, MGC and MG-QOL15 mean total scores with eculizumab during REGAIN were sustained in the eculizumab/eculizumab group during the OLE. Patients receiving open-label eculizumab after placebo during REGAIN experienced rapid improvements in assessment scores.
A clinical response (MG-ADL or QMG) was achieved by most subgroup patients receiving eculizumab during REGAIN and the OLE (
aLast observation carried forward for one patient who discontinued before REGAIN week 26.
bData calculated for patients remaining in the study at this assessment. CI, confidence interval; MG-ADL, Myasthenia Gravis Activities of Daily Living; MGC, Myasthenia Gravis Composite scale; Mg-QOL15, 15-item Myasthenia Gravis Quality of Life Questionaire; QMG, Quantitative Myasthenia Gravis test.
During REGAIN, 4/18 patients experienced exacerbations; one eculizumab-treated and three placebo-treated patients experienced 7 and 12 exacerbations, respectively. During the OLE, 6/17 patients experienced exacerbations; all six were in the eculizumab/eculizumab group. Most exacerbations occurring in eculizumab-treated patients during REGAIN (7/7 exacerbations) and the OLE (9/15 exacerbations) were experienced by one patient. The exacerbation rate was reduced by 68.6% from 150.0 exacerbations/100 patient-years in the year before REGAIN (n=18) to 47.0 exacerbations/100 patient-years during the OLE (n=17; p=0.1531). The exacerbation rate in the OLE population (n=17) also compared favorably with the REGAIN placebo group (n=9; 240.9 exacerbations per 100 patient-years; 80.4% reduction, p=0.059).
The safety profile of eculizumab in the chronic IVIg subgroup was consistent with that in all eculizumab-treated patients in REGAIN. The most common adverse events with eculizumab in this subgroup were headache (REGAIN, 22.2%; OLE, 52.9%; versus REGAIN placebo, 11.1%) and upper respiratory tract infection (33.3%, 47.1% and 33.3%, respectively). One patient in this subgroup analysis died during the OLE. This death was attributed to end-stage liver disease; the patient had cryptogenic liver cirrhosis and a history of fatty liver.
The baseline patient characteristics were similar to the REGAIN population; the IVIg subgroup had previously demonstrated poorly controlled disease by virtue of the need for chronic IVIg and the high exacerbation rate in the year before the start of the study.
During the 26-week REGAIN study and the OLE, eculizumab was associated with sustained improvements from baseline in all assessment scores in this subgroup. As in the overall OLE population, subgroup patients who received placebo in REGAIN experienced a rapid and sustained clinical response with eculizumab. During REGAIN, MG exacerbations were more frequent in subgroup patients receiving placebo versus eculizumab, consistent with active disease in this cohort. The safety profile in this group was similar to that in the overall population.
During the OLE, there were 15 exacerbations in the eculizumab/eculizumab group, but none in patients receiving placebo in REGAIN and then eculizumab (placebo/eculizumab). This discrepancy is largely attributable to one patient, who was the only eculizumab-treated patient in the subgroup to experience any exacerbations during REGAIN and who contributed over half of all exacerbations reported in the OLE. The exacerbation rate during eculizumab treatment in the OLE was reduced considerably from that in the year before REGAIN start and that in the REGAIN placebo group.
These data demonstrated that, for patients who had previously received chronic IVIg, eculizumab resulted in rapid improvements in MG signs and symptoms across four validated measures of disease severity, which were maintained over 18 months. There were also fewer MG exacerbations with eculizumab compared with placebo during REGAIN.
In this example, the response of AChR+refractory gMG patients to eculizumab enrolled in the ECU-MG-301 REGAIN Trial (see Example 1 for protocol) and the Open-Label Extension (OLE) study (ECU-MG-302; see Example 2 for protocol) was analyzed. The objective of REGAIN and the open-label extension study was to assess the tolerability of eculizumab and its efficacy, as measured by change in MG-ADL total score from each study's baseline. This sub-analysis evaluated the achievement of ‘minimal symptom expression’ in both studies, defined as achievement of an MG-ADL total score of 0-1 (range 0-24) or an MG-QOL15 total score of 0-3 (range 0-60). In contrast to current definitions of minimal symptoms, which rely on physical evaluation by a clinician, this analysis of ‘minimal symptom expression’ is based exclusively on patients' assessments of their symptoms.
In a validation study for the MG-QOL15, patients in remission had a mean MG-QOL15 total score of 3.3 (standard deviation, 4.4), with a range of 0-15. Remission was defined as an MG composite score of 0 and a score of 0 on either the MG-ADL or the MG manual muscle test, with the exception that an eye closure score of 1 (mild weakness) was permitted. The proportions of patients achieving ‘minimal symptom expression’ were calculated for the eculizumab and placebo treatment groups at week 26 of REGAIN and up to week 130 of the open-label extension (a total of 156 weeks of eculizumab treatment for the eculizumab/eculizumab group and 130 weeks of eculizumab treatment for the placebo/eculizumab group).
Adverse events were recorded and coded by preferred term using the Medical Dictionary for Regulatory Activities version 20.1. MG exacerbations, rescue therapy use and discontinuations because of adverse events were also recorded.
The significance of differences between groups was evaluated by calculating p values based on Fisher's exact test.
Results
Data are reported from the REGAIN study and its open-label extension for up to a maximum total of 156 weeks of eculizumab treatment. Of the 118 patients who completed REGAIN, 117 patients continued into the open-label study (eculizumab/eculizumab n=56, placebo/eculizumab n=61;
aAt first dose in REGAIN
bTime from MG diagnosis to date of first dose in REGAIN
At week 26 of REGAIN, a significantly higher proportion of patients receiving eculizumab achieved ‘minimal symptom expression’ than of those receiving placebo according to MG ADL score (21.4% and 1.7%, respectively; difference 19.8%; 95% confidence interval [CI] 8.5, 31.0; p=0.0007; *p<0.01; **p<0.001 vs placebo;
During the open-label extension, the proportion of patients in the eculizumab/eculizumab group with ‘minimal symptom expression’ was maintained for 2.5 years, between REGAIN week 26 and open-label week 130 (MG-ADL: 21.4% and 22.9%, respectively; MG-QOL15: 16.1% and 14.3%, respectively). In the placebo/eculizumab group, the proportion of patients with ‘minimal symptom expression’ increased to levels similar to those in the eculizumab/eculizumab group within 4 weeks of starting open-label eculizumab therapy, between REGAIN week 26 and open-label week 4 (MG-ADL: 1.7% and 21.3%, respectively; MG-QOL15: 1.7% and 17.2%, respectively). This increase was sustained to open-label week 130 (MG-ADL: 27.8%; MG-QOL15: 19.4%).
At week 130 of the open-label extension, ‘minimal symptom expression’ was achieved by similar proportions of patients in the eculizumab/eculizumab and placebo/eculizumab groups as assessed by MG-ADL score (22.9% and 27.8%, respectively; difference −4.9%; 95% CI −25.1, 15.3; p=0.7861;
There was no significant difference in mean age at first eculizumab dose between eculizumab-treated patients who achieved ‘minimal symptom expression’ according to MG-ADL during REGAIN and the open-label study (up to week 130) and those who did not (47.4 vs 47.0 years; p=0.8847). Mean disease duration at first eculizumab dose was shorter for patients who achieved ‘minimal symptom expression’ by open-label week 130 than for those who did not (8.27 [range 1.6-27.0] vs 11.16 [range 1.7-34.4] years; p=0.0474). For achievement of ‘minimal symptom expression’ according to MG-QOL15 up to open-label week 130, there were no significant differences in mean age (44.6 vs 48.4 years; p=0.2611) or mean disease duration at first eculizumab dose (8.73 [range 1.6-24.6] vs 10.51 [range 1.7-34.4] years; p=0.2091).
The mean MG-ADL total score for the open-label study population decreased from 10.1 (standard deviation [SD] 2.80; n=117) at REGAIN baseline to 3.9 (SD 3.08; n=71) at open-label week 130. The mean MG-QOL15 total score also reduced between these time points, from 31.6 (SD 12.48) to 15.3 (SD 12.15).
In conclusion, this analysis found that, at the end of REGAIN, a significantly greater proportion of patients with AChR+refractory gMG treated with eculizumab experienced ‘minimal symptom expression’ than of those receiving placebo according to an MG-ADL total score of 0-1 or an MG-QOL15 total score of 0-3. The proportions of patients experiencing ‘minimal symptom expression’ were maintained through 2.5 years of open-label eculizumab therapy in the extension study.
It is notable that, among a group of patients with refractory gMG with a mean MG-ADL total score of 10.1 at the start of REGAIN, approximately a quarter reported ‘minimal symptom expression’ defined as an MG-ADL total score of 0-1 through week 130 of the open-label study, by which time point the mean MG-ADL total score had reduced by more than half to 3.9. This reflects patient-reported improvements in disease burden in excess of the two-point reduction in MG-ADL total score that is considered to be a clinically meaningful improvement, to a level that has previously been described as disease remission.
In addition, ‘minimal symptom expression’, defined as an MG-QOL15 total score of 0-3, was achieved by one-sixth of these patients, and the mean MG-QOL15 total score halved between the start of REGAIN (31.6) and week 130 of the open-label study (15.3). The smaller proportion achieving ‘minimal symptom expression’ according to MG-ADL versus MG-QOL15 (one-quarter vs one-sixth) may be due to the conservative MG-QOL15 total score range (0-3) used in the definition of ‘minimal symptom expression’ in this analysis.
The long-term safety profile of eculizumab was consistent with its known profile from over 10 years of clinical use in other indications, and no new safety signals were observed during the open-label study.
In this example, long-term efficacy of eculizumab in responder patients enrolled in the ECU-MG-301 REGAIN Trial (see Example 1 for protocol) and the Open-Label Extension (OLE) study (ECU-MG-302; see Example 2 for protocol) was analyzed by MG-ADL and QMG score. The objective of REGAIN and the open-label extension study was to assess the tolerability of eculizumab and its efficacy, as measured by change in MG-ADL total score from each study's baseline. This sub-analysis evaluated responder data for patients enrolled in the REGAIN trial and its OLE, using MG-ADL and QMG scores. The outcomes examined included time to response and baseline/demographic factors that may predict the likelihood of response. Responder analysis baseline for eculizumab/eculizumab patients was the REGAIN baseline assessment. Responder analysis baseline for placebo/eculizumab patients was the OLE baseline assessment.
For all response assessments, patients only had to achieve a response once during the evaluation timeframe, rather than for a sustained period. An MG-ADL response was defined as an achievement of at least a three-point (i.e., ≥3-point) reduction from baseline, whereas a QMG response was defined as at least a five-point (i.e., ≥5-point) reduction from baseline. An “early responder” was defined as a response achieved on or before the Week 12 assessment of the REGAIN study. A “late responder” was defined as a response achieved on or after the Week 12 assessment of the REGAIN study. A “non-responder” was defined as no response on eculizumab up to the end of the OLE study.
Results
A total of 98 patients were evaluated in this sub-analysis, all of whom received eculizumab. Patients who received placebo during REGAIN and had an MG-ADL total score of greater than 6 at eculizumab initiation were excluded from this analysis.
An MG-ADL response was achieved by 66 patients (67.3%) at some point by Week 12 (Table 34;
A QMG response was achieved by 55 patients (56.1%) at some point by Week 12 (Table 35;
The majority of patients showed a clinically meaningful response in MG-ADL and QMG scores within the first 12 weeks of receiving eculizumab. Among these “early responders,” 30 patients (45.5%) were classified as MG-ADL responders and 20 patients (36.4%) were classified as QMG responders, at all timepoints at and following the timepoint at which the response was initially observed. The majority of MG-ADL early responders (59/66; 89.4%) and QMG early responders (43/55; 78.1%) were classified as responders at >50% of timepoints at and following the first response timepoint. After the first response, an MG-ADL response was recorded at 85.1% (941/1106) of the assessments, and a QMG response was recorded at 72.2% (642/889) of the assessments. 56.1% (37/66) of MG-ADL early responders had changes to their corticosteroid therapy. Of these, 83.8% (31/37) reduced their dose or stopped treatment. 52.7% (29/55) of QMG early responders had changes to their corticosteroid therapy. Of these, 89.7% (26/29) reduced their dose or stopped treatment.
In contrast to “early responders,” 15-17% of patients showed a clinically meaningful response at a later timepoint. Of these “late responders,” 6 patients (35.3%) were classified as MG-ADL responders and 1 patient (6.7%) was classified as a QMG responder, at all timepoints at and following the timepoint at which the response was initially observed. 12 out of 17 patients (70.6%) were classified as MG-ADL responders, and 9 out of 15 patients (60.0%) were classified as QMG responders at >50% of timepoints at and following the first response timepoint. After the first response, an MG-ADL response was recorded at 58.5% (76/130) of assessments, and a QMG response was recorded at 57.2% (83/145) of assessments. 35.3% (6/17) of MG-ADL late responders had changes to their corticosteroid therapy. Of these, 66.7% (4/6) decreased treatment. 53.3% (8/15) of QMG late responders had changes to their corticosteroid therapy. Of these, 62.5% (5/8) decreased or stopped treatment.
These findings suggest that although most patients with refractory generalized MG will achieve clinical response (assessed by MG-ADL or QMG scores) by Week 12 of eculizumab treatment, additional first responses can be observed with longer-term treatment.
†p = 0.0002 for early vs late responders based on two-sample t test
‡p = 0.0223 for early vs late responders based on two-sample t test
In this example, response of patients enrolled in the ECU-MG-301 REGAIN Trial (see Example 1 for protocol) and the Open-Label Extension (OLE) study (ECU-MG-302; see Example 2 for protocol) to eculizumab was analyzed by MG-ADL and QMG domain scores for individual muscle groups. The objective of this sub-analysis was to evaluate the MG-ADL and QMG domain scores for each muscle group in patients during REGAIN and its OLE to determine whether eculizumab is clinically beneficial across all muscle groups in patients with refractory AChR+gMG.
The MG-ADL is a patient-reported, 8-item questionnaire that reports on the functional impact of muscle weakness on activities of daily living in patients with gMG. It comprises four domains, representing ocular (two items), bulbar (three items), respiratory (one item), and limb (two items) muscle groups, which assess visual, oral, breathing, and limb motor abilities, respectively. Each item is scored from 0 to 3, with a maximum total score of 24. The QMG is an objective, physician-reported, 13-item measure of muscle strength that comprises four domains, representing ocular (three ocular and facial muscle items), bulbar (two swallowing and speech items), respiratory (one forced vital capacity item), and gross motor (seven limb and axial motor items) muscle groups. Each item is scored from 0 to 3, with a maximum total score of 39.
The scores for all domains of the MG-ADL and QMG were recorded throughout REGAIN and its OLE. Assessments were performed weekly from week 1 to week 3 and then at weeks 4, 8, 12, 16, 20, 26, 40, and 52 in year 1, then every 6 months afterward and at each patient's end-of-study visit. Patients with an abnormal score (≥0) at REGAIN baseline for a domain of either measure were included in the analysis of that domain for its respective measure. All OLE participants had at least one abnormal domain score for both MG-ADL and QMG at REGAIN baseline and were, therefore, included in the analysis of total scores. The numbers of patients in the eculizumab/eculizumab and placebo/eculizumab groups, respectively, who had abnormal REGAIN baseline scores and were included in this analysis were: for the MG-ADL domains, 55 and 59 for ocular, 54 and 55 for bulbar, 48 and 45 for respiratory, and 52 and 55 for limb; and for the QMG domains, 56 and 60 for ocular, 31 and 28 for bulbar, 28 and 36 for respiratory, and 56 and 61 for gross motor.
MG-ADL and QMG mean total and mean domain scores were calculated for both the eculizumab and the placebo groups in the REGAIN study and for the eculizumab/eculizumab and placebo/eculizumab groups in the OLE. Two baselines were used for these analyses; the REGAIN baseline (REGAIN day 1) was used to allow for assessment of response to eculizumab from the start of REGAIN, and the open-label baseline (the last available assessment before the first eculizumab dose in the OLE) was used to allow for assessment of response to eculizumab in the placebo/eculizumab group and assessment of maintenance of the response observed during REGAIN in the eculizumab/eculizumab group. Changes from REGAIN baseline to OLE week 130 (156 weeks, in total, for patients who had received eculizumab during REGAIN) and from open-label baseline to OLE week 130 were evaluated. The median duration of eculizumab treatment during the OLE (from open-label baseline to last OLE assessment) was 2.7 years (138.9 weeks; range, 0.1-196.0 weeks).
For the correlation analysis, eculizumab baseline was defined as the first dose of eculizumab received. Each regression line was determined by a simple linear regression model of change in MG-ADL total score from REGAIN baseline to last OLE assessment against change in QMG total score from eculizumab baseline to last OLE assessment, or MG-ADL total score at last OLE assessment as the response variable against QMG total score at last OLE assessment as the predictor variable, for the respective treatment groups. Its 95% confidence band was determined by the pointwise 95% confidence band. Pearson's correlation coefficients (R) by treatment group were determined for MG-ADL and QMG total score changes from eculizumab baseline to last OLE assessment and for MG-ADL and QMG total scores at last OLE assessment; thresholds for moderate and strong correlations were 0.4 and 0.6, respectively.
Repeated-measures analyses for changes in MG-ADL and QMG total and domain scores from open-label baseline were performed. These data are presented as least-squares means and 95% confidence intervals (CIs).
MG-ADL and QMG and QMG Total Scores
For patients in the eculizumab/eculizumab group, the improvements achieved in both MG-ADL and QMG mean total scores during REGAIN and the interim analysis of OLE data were found to be sustained in this final analysis of the complete OLE data through 130 weeks (
Correlation Between MG-ADL and QMG Scores
In the eculizumab/eculizumab group, there were strong correlations between changes in MG-ADL and QMG total scores from eculizumab baseline to last OLE assessment (R=0.73; 95% CI, 0.57-0.83;
The strong correlations between MG-ADL and QMG total scores, both for changes from eculizumab baseline to last OLE assessment and at last OLE assessment, demonstrate that the long-term effect of eculizumab is consistent between the MG-ADL and QMG assessments. This finding further validates use of the MG-ADL in assessing response to treatment in MG and also provides evidence that patient-reported improvements in response to long-term eculizumab treatment are supported by objective physician assessments of patients with refractory AChR+gMG.
MG-ADL Domain Scores
Patients in the eculizumab/eculizumab group experienced rapid improvements across all four MG-ADL domains during REGAIN, and this treatment effect was sustained through 130 weeks of the OLE (
In the placebo/eculizumab group, statistically significant improvements in scores from open-label baseline were observed in the ocular, bulbar, and limb domains as early as week 1 and remained significant at each time point through 130 weeks (*p≤0.05, †p≤0.01, ‡p≤0.001;
QMG Domain Scores
Patients in the eculizumab/eculizumab group experienced rapid improvements across all four QMG domains during REGAIN, and this treatment effect was sustained through 130 weeks of the OLE (
In the placebo/eculizumab group, statistically significant improvements from open-label baseline were observed across all domains by week 1, except for the bulbar domain, which was first significantly improved at week 40 (*p≤0.05, †p≤0.01, ‡p≤0.001;
In contrast to other MG therapies that have been reported to have differential effects across muscle groups, eculizumab had benefits that were evident across the MG-ADL domains for all four muscle groups, demonstrating that eculizumab improves patients' breathing and functioning in a wide range of activities of daily living through at least 130 weeks. These patient-reported improvements were supported by objective, physician-reported improvements in muscle strength with eculizumab as evaluated by QMG domain scores across all four muscle groups through at least 130 weeks. It is notable that these improvements were achieved by patients with refractory disease, a population with significant disease burden, and that most participants completed the OLE.
E1. 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 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 treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment.
E2. The method of embodiment E1, wherein the anti-C5 antibody is eculizumab.
E3. The method of embodiment E2, 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, 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.
E4. The method of embodiment E2, 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.
E5. The method of embodiment E2, 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.
E6. The method of embodiment E2, 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.
E7. The method of embodiment E1, wherein the therapeutically effective amount is based on the weight of the subject.
E8. The method of embodiment E1, wherein the anti-C5 antibody is ravulizumab.
E9. The method of embodiment E8, wherein ravulizumab, or an antigen binding fragment thereof is administered to a patient weighing ≥40 and <60 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 2400 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3000 mg.
E10. The method of embodiment E8, wherein ravulizumab, or an antigen binding fragment thereof is administered to a patient weighing ≥60 and <100 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 2700 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3300 mg.
E11. The method of embodiment E8, wherein ravulizumab, or antigen binding fragment thereof, is administered to a patient weighing ≥100 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 3000 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3600 mg.
E12. The method of embodiment E1, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 4 weeks of treatment.
E13. The method of embodiment E1, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 12 weeks of treatment.
E14. The method of embodiment E1, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 26 weeks of treatment.
E15. The method of embodiment E1, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 52 weeks of treatment.
E16. The method of embodiment E1, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 66 weeks of treatment.
E17. The method of embodiment E1, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 78 weeks of treatment.
E18. The method of embodiment E1, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 104 weeks of treatment.
E19. The method of embodiment E1, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 130 weeks of treatment.
E20. The method of embodiment E1, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 156 weeks of treatment.
E21. The method of any one of embodiments E1-E14, wherein the patient achieves a MGFA post-intervention status of Improved.
E22. The method of any one of embodiments E1-E14, wherein the patient achieves a MGFA post-intervention status of MM.
E23. The method of embodiment E1, wherein the patient experiences a clinically meaningful improvement (reduction) in a measurement of generalized myasthenia gravis severity after 26 weeks of treatment selected from the group consisting of Myasthenia Gravis Activities of Daily Living (MG-ADL) score, quantitative Myasthenia Gravis (QMG), score and Myasthenia Gravis Composite (MGC) score.
E24. The method of embodiment E23, wherein the clinically meaningful improvement the patient experiences is an at least a 3 point reduction in the patient's MG-ADL score after 26 weeks of treatment.
E25. The method of embodiment E23, wherein the clinically meaningful improvement the patient experiences is an at least a 4 point reduction in the patient's QMG score after 26 weeks of treatment.
E26. The method of embodiment E23, wherein the clinically meaningful improvement the patient experiences is an at least a 6 point reduction in the patient's MGC score after 26 weeks of treatment.
E27. The method of embodiment E1, 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.
E28. The method of embodiment E27, wherein the clinically meaningful improvement the patient experiences is an at least a 6 point reduction in the patient's MG-QOL-15 score after 26 weeks of treatment.
E29. The method of embodiment E1, wherein the patient experiences a clinically meaningful improvement (reduction) in neuro-fatigue as measured by Neuro-QOL Fatigue score after 26 weeks of treatment.
E30. The method of embodiment E29, wherein the clinically meaningful improvement the patient experiences is an at least an 8 point reduction in the patient's Neuro-QOL score after 26 weeks of treatment.
E31. The method of embodiment E1, 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.
E32. A method of treating refractory generalized myasthenia gravis in a patient in need thereof comprising administering an anti-C5 antibody or an antigen binding fragment thereof to the patient;
(a) once on Day 1 of the administration cycle at a loading dose of 2400 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3000 mg.
E38. The method of embodiment E36, wherein ravulizumab, or an antigen binding fragment thereof is administered to a patient weighing ≥60 and <100 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 2700 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3300 mg.
E39. The method of embodiment E36, wherein ravulizumab, or antigen binding fragment thereof, is administered to a patient weighing ≥100 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 3000 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3600 mg.
E40. A method of treating refractory generalized myasthenia gravis in a patient in need thereof comprising administering an anti-C5 antibody or an antigen binding fragment thereof 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 the patient is treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment; 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.
E41. The method of embodiment E40, wherein the anti-C5 antibody is eculizumab.
E42. The method of embodiment E41 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, 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.
E43. The method of embodiment E40, wherein the therapeutically effective amount is based on the weight of the subject.
E44. The method of embodiment E40, wherein the anti-C5 antibody is ravulizumab.
E45. The method of embodiment E44, wherein ravulizumab, or an antigen binding fragment thereof is administered to a patient weighing ≥40 and <60 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 2400 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3000 mg.
E46. The method of embodiment E44, wherein ravulizumab, or an antigen binding fragment thereof is administered to a patient weighing ≥60 and <100 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 2700 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3300 mg.
E47. The method of embodiment E44, wherein ravulizumab, or antigen binding fragment thereof, is administered to a patient weighing ≥100 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 3000 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3600 mg.
E48. The method of embodiment E40, 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.
E49. A method of maintaining a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) in a patient with refractory generalized myasthenia gravis 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 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 had achieved the Improved or MM status.
E50. The method of embodiment E49, wherein the anti-C5 antibody is eculizumab.
E51. The method of embodiment E50, 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, 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.
E52. The method of embodiment E50, 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.
E53. The method of embodiment E50, 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.
E54. The method of embodiment E50, 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.
E55. The method of embodiment E49, wherein the therapeutically effective amount is based on the weight of the subject.
E56. The method of embodiment E49, wherein the anti-C5 antibody is ravulizumab.
E57. The method of embodiment E56, wherein ravulizumab, or an antigen binding fragment thereof is administered to a patient weighing ≥40 and <60 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 2400 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3000 mg.
E58. The method of embodiment E56, wherein ravulizumab, or an antigen binding fragment thereof is administered to a patient weighing ≥60 and <100 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 2700 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3300 mg.
E59. The method of embodiment E56, wherein ravulizumab, or antigen binding fragment thereof, is administered to a patient weighing ≥100 kg:
(a) once on Day 1 of the administration cycle at a loading dose of 3000 mg; and
(b) on Day 15 of the administration cycle and every eight weeks thereafter at a maintenance dose of 3600 mg.
E60. The method of embodiment E49, wherein the Improved or MM status is maintained for at least 4, 12, 26, 52, 66, 78, 104, 130 or 156 weeks.
E61. The method of embodiment E49, wherein the patient starts the maintenance with the MM status.
E62. The method of embodiment E49, wherein the MM status is maintained for at least 4, 12, 26, 52, 66, 78, 104, 130 or 156 weeks.
E63. The method of any of the preceding embodiments, wherein the anti-C5 antibody or antigen binding fragment thereof is administered by intravenous infusion.
E64. The method of any of the preceding embodiments, wherein the anti-C5 antibody or antigen binding fragment thereof is administered subcutaneously.
E65. The method of any of the preceding embodiments, 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.
E66. The method of any of the preceding embodiments, wherein ravulizumab comprises 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.
E67. The method of any of the preceding embodiments, wherein the patient has failed treatment over one year or more with two or more ISTs in sequence or in combination.
E68. The method of any of the preceding embodiments, wherein the patient has failed at least one IST and requires chronic plasma exchange or IVIg to control symptoms.
E69. The method of any of the preceding embodiments, wherein the therapeutically effective amount of the anti-C5 antibody or antigen binding fragment thereof is maintained at a concentration of between 50-100 μg/mL in the patient's serum.
E70. The method of any of the preceding embodiments, wherein the patient experiences a reduction in the administration of one or more IST following at least 26 weeks of treatment.
E71. The method of any of the preceding embodiments, wherein the patient experiences a reduction in IST dosing following at least 26 weeks of treatment.
E72. The method of any of the preceding embodiments, 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.
E73. The method of any of the preceding embodiments, wherein the anti-C5 antibody or an antigen binding fragment thereof is selected from the group consisting of eculizumab, ravulizumab, BNJ421, 7086 antibody, 8110 antibody, 305LO5, SKY59 and REGN3918.
E74. The method of any one of embodiments E1, E32, E40 and E49, wherein a patient switches from receiving one anti-C5 antibody or antigen binding fragment thereof to a different anti-C5 antibody or antigen binding fragment thereof during the course of treatment.
E75. The method of any one of embodiment E1, E32, E40 and E49, wherein different anti-C5 antibodies may be administered during separate treatment periods.
E76. An anti-C5 antibody or an antigen binding fragment thereof for use in treating refractory generalized myasthenia gravis in a patient in need thereof;
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 treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment.
E77. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E76, 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, 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.
E78. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E76 or embodiment E77, 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.
E79. An anti-C5 antibody or an antigen binding fragment thereof for the use according to of embodiment E76 or embodiment E77, 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.
E80. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E76 or embodiment E77, 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.
E81. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E80, wherein the therapeutically effective amount is based on the weight of the subject.
E82. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E81, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 4 weeks of treatment.
E83. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E82, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 12 weeks of treatment.
E84. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E83, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 26 weeks of treatment.
E85. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E84, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 52 weeks of treatment.
E86. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E85, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 66 weeks of treatment.
E87. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E86, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 78 weeks of treatment.
E88. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E87, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 104 weeks of treatment.
E89. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E88, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 130 weeks of treatment.
E90. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E89, wherein the patient achieves a MGFA post-intervention status of Improved or MM after 156 weeks of treatment.
E91. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E90, wherein the patient achieves a MGFA post-intervention status of Improved.
E92. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76-E90, wherein the patient achieves a MGFA post-intervention status of MM.
E93. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E92, wherein the patient experiences a clinically meaningful improvement (reduction) in a measurement of generalized myasthenia gravis severity after 26 weeks of treatment selected from the group consisting of Myasthenia Gravis Activities of Daily Living (MG-ADL) score, quantitative Myasthenia Gravis (QMG), score and Myasthenia Gravis Composite (MGC) score.
E94. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E93, wherein the clinically meaningful improvement the patient experiences is an at least a 3 point reduction in the patient's MG-ADL score after 26 weeks of treatment.
E95. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E93, wherein the clinically meaningful improvement the patient experiences is an at least a 4 point reduction in the patient's QMG score after 26 weeks of treatment.
E96. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E93, wherein the clinically meaningful improvement the patient experiences is an at least a 6 point reduction in the patient's MGC score after 26 weeks of treatment.
E97. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E96, 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.
E98. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E97, wherein the clinically meaningful improvement the patient experiences is an at least a 6 point reduction in the patient's MG-QOL-15 score after 26 weeks of treatment.
E99. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiment E76 to E98, wherein the patient experiences a clinically meaningful improvement (reduction) in neuro-fatigue as measured by Neuro-QOL Fatigue score after 26 weeks of treatment.
E100. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E99, wherein the clinically meaningful improvement the patient experiences is an at least an 8 point reduction in the patient's Neuro-QOL score after 26 weeks of treatment.
E101. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E100, 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.
E102. An anti-C5 antibody or an antigen binding fragment thereof for use in 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 the patient is treated for at least 52 weeks and achieves a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) after at least 4 weeks of treatment; 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.
E106. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E105 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, 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.
E107. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E105, wherein the therapeutically effective amount is based on the weight of the subject.
E108. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E105 to E107, 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.
E109. An anti-C5 antibody or an antigen binding fragment thereof for use in maintaining a Myasthenia Gravis Foundation of America (MGFA) post-intervention status of Improved or Minimal Manifestations (MM) in a patient with refractory generalized myasthenia gravis 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 had achieved the Improved or MM status.
E110. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E109, 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, 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.
E111. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E109 or embodiment E110, 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.
E112. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E109 or embodiment E110, 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.
E113. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E109 or embodiment E110, 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.
E114. An anti-C5 antibody or an antigen binding fragment thereof for the use according to embodiment E109, wherein the therapeutically effective amount is based on the weight of the subject.
E115. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E109 to E114, wherein the Improved or MM status is maintained for at least 4, 12, 26, 52, 66, 78, 104, 130 or 156 weeks.
E116. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E109 to E114, wherein the patient starts the maintenance with the MM status.
E117. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E109 to E114, wherein the MM status is maintained for at least 4, 12, 26, 52, 66, 78, 104, 130 or 156 weeks.
E118. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E117, wherein eculizumab is administered by intravenous infusion.
E119. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of any one of embodiments E76 to E118, wherein the eculizumab is administered subcutaneously.
E120. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E119, 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.
E121. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E120, wherein the patient has failed treatment over one year or more with two or more ISTs in sequence or in combination.
E122. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E120, wherein the patient has failed at least one IST and requires chronic plasma exchange or IVIg to control symptoms.
E123. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E122, wherein the therapeutically effective amount of eculizumab is maintained at a concentration of between 50-100 μg/mL in the patient's serum.
E124. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E123, wherein the patient experiences a reduction in the administration of one or more IST following at least 26 weeks of treatment.
E125. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E124, wherein the patient experiences a reduction in IST dosing following at least 26 weeks of treatment.
E126. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E125, wherein the patient experiences a reduction in IST dosing and a discontinuation in one or more IST following at least 26 of treatment.
E127. An anti-C5 antibody or an antigen binding fragment thereof for the use according to any one of embodiments E76 to E126, wherein the patient switches from receiving one anti-C5 antibody or antigen binding fragment thereof to eculizumab during the course of treatment.
The following references are hereby incorporated by reference in their entirety:
This application claims the benefit of priority to U.S. Provisional Patent Application No. 62/882,892, filed Aug. 5, 2019, U.S. Provisional Patent Application No. 62/890,429, filed Aug. 22, 2019, U.S. Provisional Patent Application No. 62/915,550, filed Oct. 15, 2019, U.S. Provisional Patent Application No. 62/944,670, filed Dec. 6, 2019, U.S. Provisional Patent Application No. 62/966,967, filed Jan. 28, 2020, and U.S. Provisional Patent Application No. 62/981,901, filed Feb. 26, 2020, the entire contents of which are incorporated herein by reference for all purposes.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US2020/044894 | 8/4/2020 | WO |
| Number | Date | Country | |
|---|---|---|---|
| 62882892 | Aug 2019 | US | |
| 62890429 | Aug 2019 | US | |
| 62915550 | Oct 2019 | US | |
| 62944670 | Dec 2019 | US | |
| 62966967 | Jan 2020 | US | |
| 62981901 | Feb 2020 | US |
