Patent Application
20170182178
A sequence listing designated 0019-00411PC ST25.txt of 3KB created Apr. 1, 2015, is incorporated herein by reference.
This invention relates to optimal dose regimens for treatment of B-linage acute lymphoblastic leukemia (B-ALL or ALL) using a CD19-antibody drug conjugate.
CD19 is a member of the immunoglobulin superfamily. See, e.g., Tedder & Isaacs, J Immunol, 143:712-717 (1989) and Del Nagro et al., Immunol Res, 31:119-131 (2005). It is a B cell-specific marker not known to be expressed by any cell outside of the B lineage. CD19 expression is maintained upon malignant transformation, thus, CD19 is found on malignant cells in the majority of patients with B-cell leukemia or non-Hodgkin lymphoma. See, e.g., Nadler et al., J Immunol, 131:244-250 (1983); Anderson et al., Blood, 63:1424-1433 (1984); and Scheuermann & Racila, Leuk Lymphoma, 18:385-397 (1995).
SGN-CD19A is a CD19-directed antibody-drug conjugate (ADC) consisting of three components: 1) the humanized antibody hBU12, specific for human CD19, 2) the microtubule disrupting agent, monomethyl auristatin F (MMAF), and 3) a stable linker, maleimidocaproyl, that covalently attaches MMAF to hBU12. The proposed mechanism of action (MOA) is initiated by SGN-CD19A binding to CD19 on the cell surface followed by internalization of the ADC. Upon trafficking to lysosomes, the delivered drug (cysmcMMAF) is released through proteolytic degradation of the antibody carrier. Binding of the released drug to tubulin disrupts the microtubule network, leading to cell cycle arrest and apoptosis.
SGN-CD19A activity has recently been assessed in a phase 1 clinical trial for treatment of patients with B-linage acute lymphoblastic leukemia (B-ALL). The trial is intended to provide information on the safety of the SGN-CD19A molecule in a human patient population. Clinical trials also provide data on the pharmacokinetics and efficacy of the SGN-CD19A molecule in treating B-ALL. For best usage of the drug, an optimum dosing regimen would be useful for prescribing physicians. The present invention solves this and other problems.
The disclosure provides a method of treating a subject with acute lymphoblastic leukemia (ALL) by first administering a loading dose of a CD19-antibody drug conjugate, wherein the CD19-antibody drug conjugate (CD19-ADC) is a humanized BU12 antibody conjugated to an mcMMAF molecule, followed by administering a maintenance dose of the CD19-antibody drug conjugate, the maintenance dose being 2.0 mg/kg body weight every three weeks. The humanized hBU12 antibody has a light chain variable region of SEQ ID NO:1 and a heavy chain variable region of SEQ ID NO:2. In some embodiments, the subject has a high disease burden and is sensitive to treatment with the CD19 ADC; the loading dose for such subject is 2.0 mg/kg body weight and is administered on days one and eight of a three week cycle. The loading dose can be administered in a single three week cycle or two three or four loading doses can be administered before a maintenance dose is started. The 2 mg/kg maintenance dose is administered on day one of a three week cycle for multiple three week cycles. In some embodiments, maintenance doses are given for between one and ten three week cycles. In further embodiments, maintenance doses are given for between ten and twenty three week cycles. In preferred embodiments, the administration of the CD19 ADC is intravenous administration. In further embodiments, the CD19 ADC maintenance dose is administered at a dose required to maintain 90% occupancy of the CD19 receptor on blast cells.
In one embodiment, the disclosure provides a method of treating a subject with ALL that has a high disease burden and is insensitive to treatment with the CD19 ADC using a loading dose followed by a maintenance dose. Such a subject is treated with a 5 mg/kg loading dose of the CD19-ADC that is a humanized BU12 antibody conjugated to an mcMMAF molecule, which is administered on days one and eight of a three week cycle. The loading dose can be administered in a single three week cycle or two three or four loading doses can be administered before a maintenance dose is started. The maintenance dose is 3 mg/kg and is administered on day one of a three week cycle for multiple three week cycles. In some embodiments, maintenance doses are given for between one and ten three week cycles. In further embodiments, maintenance doses are given for between ten and twenty three week cycles. In preferred embodiments, the administration of the CD19 ADC is intravenous administration. In further embodiments, the CD19 ADC maintenance dose is administered at a dose required to maintain 90% occupancy of the CD19 receptor on blast cells.
In one embodiment, the disclosure provides a method of treating a subject having acute lymphoblastic leukemia (ALL) by administering a fixed dose of a CD19-antibody drug conjugate, wherein the CD19-antibody drug conjugate (CD19-ADC) is a humanized BU12 antibody conjugated to an mcMMAF molecule, wherein the dose intensity is about 1 mg/kg/week. The humanized hBU12 antibody has a light chain variable region of SEQ ID NO:1 and a heavy chain variable region of SEQ ID NO:2. In one embodiment, the fixed dose is 1.6 mg/kg body weight and is administered on days one and seven of a three week cycle. In another embodiment, the fixed dose is 2.2 mg/kg body weight and is administered every two weeks. In a further embodiment, the fixed dose is 3.0 mg/kg body weight and is administered every three weeks. In some embodiments, fixed doses are given for between one and ten cycles. In further embodiments, fixed doses are given for between ten and twenty cycles. In additional embodiments, fixed doses are administered for up to 50 cycles. In preferred embodiments, the administration of the CD19 ADC is intravenous administration. In further embodiments, the CD19 ADC maintenance dose is administered at a dose required to maintain 90% occupancy of the CD19 receptor on blast cells.
The term “CD19” refers to “cluster of differentiation protein 19”, a human protein that is expressed on human B cells. The amino acid sequence of human CD19 is known and is disclosed, e.g., at NCBI Reference Sequence: NP_001171569.1.
A “disorder”, as used herein, and the terms “CD19-associated disorder” and “CD19-associated disease” refer to any condition that would benefit from treatment with a CD19-antibody drug conjugate (CD19-ADC), such as SGN-CD19A, as described herein. This includes chronic and acute disorders or diseases including those pathological conditions that predispose the mammal to the disorder in question. Non-limiting examples or disorders to be treated herein include CD19 expressing cancers, including hematological malignancies, benign and malignant tumors, leukemias and lymphoid malignancies, as well as inflammatory, angiogenic and immunologic disorders. Specific examples of disorders are disclosed infra.
B cell malignancies, also referred to as B-cell lineage malignancies, are treatable by the methods of the present invention. The term B cell malignancies include any malignancy that is derived from a cell of the B cell lineage.
The terms “treatment” and “therapy”, and the like, as used herein, are meant to include therapeutic or suppressive measures for a disease or disorder leading to any clinically desirable or beneficial effect, including, but not limited to, alleviation or relief of one or more symptoms, regression, slowing or cessation of progression of the disease or disorder. For example, treatment can include a decrease or elimination of a clinical or diagnostic symptom of a CD19-expressing disorder after the onset of the clinical or diagnostic symptom by administration of an anti-CD19 antibody or other CD19 binding agent to a subject. Treatment can be evidenced as a decrease in the severity of a symptom, the number of symptoms, or frequency of relapse.
Except when noted, the terms “subject” or “patient” are used interchangeably and refer to mammals such as human patients and non-human primates, as well as experimental animals such as rabbits, dogs, cats, rats, mice, and other animals. Accordingly, the term “subject” or “patient” as used herein means any mammalian patient or subject to which the CD19 binding agents of the invention can be administered. In preferred embodiments, the terms subject or patient are used to refer to human patients. Subjects of the present invention include those that have been diagnosed with a CD19 expressing cancer, including, for example, B cell lymphoma or B cell leukemia, including, but not limited to, non-Hodgkin lymphoma, chronic lymphocytic leukemia, and acute lymphoblastic leukemia. In certain embodiments, the subject will have a refractory or relapsed CD19 expressing cancer
A subject with a refractory CD19 expressing cancer is a subject who does not respond to therapy, i.e., the subject continues to experience disease progression despite therapy.
A subject with a relapsed CD19 expressing cancer is a subject who has responded to the therapy at one point, but has had a recurrence or further progression of disease following the response.
The term “effective amount” refers to the amount of a CD19-ADC, e.g., SGN-CD19A, that is sufficient to inhibit the occurrence or ameliorate one or more clinical or diagnostic symptoms of a CD19-associated disorder in a subject. An effective amount of an agent is administered according to the methods described herein in an “effective regimen.” The term “effective regimen” refers to a combination of amount of the agent and dosage frequency adequate to maintain high CD19 occupancy, which may accomplish treatment or prevention of a CD19-associated disorder. In a preferred embodiment, an effective regimen maintains near complete, e.g., greater than 90%, CD19 occupancy on CD19-expressing cells during dosing intervals.
The term “pharmaceutically acceptable” as used herein refers to those compounds, materials, compositions, and/or dosage forms that are, within the scope of sound medical judgment, suitable for contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problems or complications commensurate with a reasonable benefit/risk ratio. The term “pharmaceutically compatible ingredient” refers to a pharmaceutically acceptable diluent, adjuvant, excipient, or vehicle with which a CD19-ADC, e.g., SGN-CD19A is administered.
The term “pharmaceutically compatible ingredient” refers to a pharmaceutically acceptable diluent, adjuvant, excipient, or vehicle with which a CD19-ADC, e.g., SGN-CD19A, is administered.
As used herein, the term “about” denotes an approximate range of plus or minus 10% from a specified value. For instance, the language “about 20%” encompasses a range of 18-22%. As used herein, about also includes the exact amount. Hence “about 20%” means “about 20%” and also “20%.”
This invention provides optimized dosage schedules for administration of the SGN-CD19A drug to patients suffering from acute lymphoblastic leukemia (ALL). Results from an early stage clinical trial indicate that SGN-CD19A exhibits a complex relationship between pharmacokinetics (PK) and pharmacodynamics (PD). A model was generated to describe the relationship of SGN-CD19A clearance and its effect on ALL tumor cells. Using the model, SGN-CD19A dosing schedules can be devised to maximize tumor cell cytotoxicity and minimize off target toxicity in the patient.
SGN-CD19A is an antibody drug conjugate (ADC) produced by the conjugation of the drug-linker intermediate maleimidocaproyl monomethyl auristatin F (mcMMAF) to the humanized antibody hBU12 (
Methods of making the hBU12 antibody are disclosed, e.g., at U.S. Pat. No. 7,968,687. The amino acid sequence of the light chain variable region of hBU12 is provided herein as SEQ ID NO:1. The amino acid sequence of the heavy chain variable region of hBU12 is provided herein as SEQ ID NO:2. hBU12 is an IgG1 antibody and the variable regions are joined to human heavy and light constant regions. U.S. Pat. No. 7,968,687 also provides methods for the synthesis of mcMMAF and its conjugation to hBU12.
SGN-CD19A, therefore, is an ADC that delivers mcMMAF to CD19-positive cells. mcMMAF is a tubulin-binding molecule. SGN-CD19A has a proposed multi-step mechanism of action initiated by binding to their target on the cell surface and subsequent internalization. After cell surface binding, internalization, and trafficking of SGN-CD19A through the endocytic pathway, proteolytic degradation of hBU12 in the lysosomes releases the cysteine adduct of the drug linker in the form of cys-mcMMAF, which then becomes available for tubulin binding. See, e.g., Doronina et al., Nat Biotechnol 21:778-84 (2003) and Doronina et al., Bioconjug Chem 17:114-24 (2006). cys-mcMMAF and mcMMAF are used interchangeably herein. Binding of the released drug to tubulin disrupts the cellular microtubule network, leading to G2/M phase cell cycle arrest and subsequent onset of apoptosis in the targeted cell.
The model described herein is used to optimize dosing of SGN-CD19A for treatment of acute lymphoblastic leukemia (ALL). ALL is also known as B-lineage acute lymphoblastic leukemia (B-ALL) and both names are used interchangeably. ALL is a cancer of the white blood cells that is characterized by uncontrolled growth of lymphoblasts or immature white blood cells. Lymphoblasts are also referred to as “blasts”, herein. Blasts typically grow in the bone marrow and crowd out normal blood cells. Blasts cells may be seen in blood, but diagnoses is typically done be review of bone marrow biopsy.
Based on the PK and PD values from patients after administration of SGN-CD19A, a model was generated to describe the observed PK and PD data, and subsequently to determine optimal dosage of SGN-CD19A based on CD19 occupancy. See, e.g.,
Some assumptions underlie the model. First, the distribution kinetics of unbound SGN-CD19A (drug) to tissues is linear and may be described by inter-compartment rate constants. Second, SGN-CD19A is highly specific and does not bind to targets other than CD19. Third, the drug-CD19 binding occurs only in the central compartment and not in the peripheral (tissue) compartments. Fourth, the drug-CD19 binding is a rapid process and results in simple one-to-one drug-target complex. Fifth, the binding of SGN-CD19A to the CD19 protein results in internalization and degradation of the drug-CD19 complex, which results in the released of the small molecule cytotoxin (cys-mcMMAF). Sixth, CD19 synthesis and degradation rates are constant in all blast cells in a given patient and are not affected by the treatment. Seventh, the majority of blast cells reside in bone marrow space.
The model structure is shown in
SGN-CD19A is formulated for patients in a sterile pharmaceutically acceptable excipient and then administered to patients. Typically, administration is by intravenous methods. A preferred pharmaceutically acceptable formulation for SGN-CD19A is 15 mg/ml in 10 mM potassium phosphate, pH 6.0, 0.02% w/v polysorbate 80, and 60 mg/ml sucrose.
The methods of the present invention provide optimized dosing schedules of SGN-CD19A for treatment of ALL. The optimal doses and schedules were determined based on a number of patient disease characteristics, for example, disease burden and CD19 expression levels. High disease burden in this model was defined as a packed (100% replaced), hypercellular bone marrow as assessed on bone marrow biopsy or aspirate. Low disease burden was defined as 10% of the bone marrow replaced by blasts as assessed on bone marrow biopsy or aspirate. High CD19 expression was defined as a CD19 MFI value of 45 at baseline and low expression was 4.5 at baseline. Another relevant characteristic is the sensitivity (coefficient of 0.00019 on drug effect) or lack of sensitivity (coefficient of 0.00006) of the cancer to an anti-CD19 treatment, such as SGN-CD19A.
SGN-CD19A can be administered to ALL patients on a fixed dose schedule. A fixed dose schedule is a schedule that is unvaried over time. For SGN-CD19A administration on a fixed dose schedule, it is important to maintain the dose intensity, i.e., the amount of SGN-CD19A per unit of patient weight per unit of time, at about 1 mg/kg/week. This dose intensity will be beneficial to patients regardless of their disease burden or sensitivity to treatment. Thus, acceptable fixed dose schedules of SGN-CD19A include 1.6 mg/kg given on days one and eight of a three week cycle, 2.2 mg/kg every two weeks, or 3.0 mg/kg every three weeks.
SGN-CD19A can also be administered to ALL patients using a higher loading dose and/or more frequent loading doses followed by lower and/or less frequent maintenance doses. Typically, the loading dose is greater than the maintenance dose. For patients who have high disease burden and are sensitive to treatment, 2 mg/kg given every three weeks is an acceptable maintenance dose following one cycle of 2 mg/kg given on days one and eight of a three week cycle. Typically a single cycle of loading dose of more frequent dosing is given, but more can be administered, as needed, to decrease disease burden and induce remission before switching to maintenance dose schedule. Thus, one, two three or four loading doses can be given before starting maintenance doses. Maintenance doses are given, e.g., for two-20 three week cycles, at the 2 mg/kg dose level.
For patients who have high disease burden and are less sensitive to treatment, 3 mg/kg given every three weeks is an acceptable maintenance dose following a loading dose of 5 mg/kg given every three weeks. Typically a single loading dose is given, but more can be administered, as needed, to decrease disease burden and induce remission. For some patients, multiple loading doses, e.g., one, two three or four loading doses loading doses can be given before starting maintenance doses. Maintenance doses are given, e.g., for two-20 three week cycles, at the 3 mg/kg dose level.
The following examples are offered to illustrate, but not to limit the claimed invention.
SGN-CD19A was administered intravenously (IV) on a weekly schedule (first 2 weeks of a 21-day cycle on Days 1 and 8. Dose levels were escalated. Adult patients were initially enrolled in cohorts of 2, starting with dose level 1. For the first 6 patients, complete dose limiting toxicity information was available before the next patient cohort was enrolled. After the first 6 patients, 3 patients at a time could be enrolled and in the DLT period. Once one patient finished the DLT period, another patient could be enrolled. Estimates of safety were determined by a continuous reassessment model, and an algorithm allocated patients to dose levels. Dose levels are shown in Table 1.
Plasma SGN-CD19A levels—SGN-CD19A was administered on days 1 and 8 of a 21 day cycle at the indicated dose levels. Blood was drawn from patients at the schedule time for PK and PD measurements (Table 2). The concentrations of plasma SGN-CD19A were determined using enzyme linked immunosorbent assays (ELISA). Briefly, a monoclonal antibody specific to the MMAF portion of the antibody-drug conjugate was used to capture the SGN-CD19A antibody from plasma. Bound SGN-CD19A was detected by a biotin conjugated anti-ID19A detection antibody followed by addition of a polymer horseradish peroxidase conjugated to streptavidin (poly HRP-SA). For detection TMB (3,3′,5,5′ tetramethylbenzidine) was used which was converted from colorless TMB to a colored TMB derivative.
Unbound CD19 receptor protein on blasts—Blasts were isolated from cryopreserved patient blood and incubated labeled hBU12 antibody (hBU12-AF488). After incubation the cells were assayed by flow cytometry for its fluorescence intensity expressed as mean fluorescence intensity (MFI).
SGN-CD19A bound to blast cells—Blast cells were isolated from patient blood and incubated with a labeled antibody specific for MMAF (SG15.22-AF647). After washing to remove unbound labeled antibody, cells were assayed by flow cytometry for its fluorescence intensity expressed as MFI.
xb
aSample obtained only for patients not continuing on treatment or not starting the next cycle on Day 22.
bCycle 2 only.
cThis schedule should be followed for retreatment cycle 1
Patient disease was monitored by bone marrow aspiration and/or biopsy at indicated times. A pathologist reviewed bone marrow slides from patients and assessed for percentage of bone marrow cells that were malignant blasts, as well as the total amount of space in the bone marrow that was taken up by cells (cellularity). Disease burden was a product of the cellularity and the percentage of the bone marrow that was replaced by malignant blasts.
SGN-CD19A was administered to ALL patients at levels up to 2.0 mg/kg on days 1 and 8 of a 21 day cycle. Plasma levels of SGN-CD19A were measured per protocol-defined schedule (Table 2). Results are shown in
A semi-mechanistic integrated PK-PD model was developed based on the mechanism of action of SGN-CD19A and the clinical PK and PD data from the ongoing first-in-human dose-escalation study in adult and pediatric patients with relapsed or refractory B cell leukemia or highly aggressive B-cell lymphoma (CT.gov NCT01786096). Plasma SGN-CD19A ADC concentration-time profiles were described by a two-compartment PK model with both linear and nonlinear clearance pathways. The nonlinear clearance was modeled as target-mediated disposition through binding to cell membrane CD19 and internalization of the complex. Anti-tumor effects in the form of reduced bone marrow disease burden were modeled using a cell-kill PK-PD model driven by the internalized cys-mcMMAF concentrations. Both PK and PD data were fitted simultaneously using NONMEM® version 7.1.2. At low levels of administration, SGN-CD19A exhibited a biphasic PK curve, indicating rapid clearance of the drug. As the dose of SGN-CD19A increased the PK curve became monophasic indicating slower clearance of the drug. SGN-CD19A clearance occurred through two mechanisms: clearance through whole body catabolism and clearance through uptake by tumor cells. Over time SGN-CD19A was taken up by ALL tumor cells, killing the tumor cells and reducing the tumor burden. Thus, over time, the rate of clearance through tumor uptake decreased and less SGN-CD19A was needed to kill tumor cells.
To determine the goodness of model fit, model-predicted values were compared to values observed from patient samples. Results are shown in
Model simulations were conducted for alternative doses and schedules, including more frequent dose or loading dose regimens followed by maintenance dose regimens, and for ALL patients with different baseline disease characteristics.
The first simulation was for an ALL patient with high baseline CD19 expression and 100% bone marrow blasts and hypercellularity in bone marrow. SGN-CD19A was administered on a fixed dosage schedules: 1.6 mg/kg on days 1 and 8 of a 21 day cycle; 2.2 mg/kg every two weeks; or 3 mg/kg every three weeks. The model was used to predict the percentage of CD19 on blast cells that were bound to SGN-CD19A (CD19 occupancy). High target saturation was assumed to occur if 90% of the CD19 proteins on blasts were occupied.
A simulation was run for an ALL patient with high baseline CD19 expression and 10% bone marrow blasts and hypercellularity. SGN-CD19A was administered on a fixed dosage schedules: 1.6 mg/kg on days 1 and 7 of a 21 day cycle; 2.2 mg/kg every two weeks; or 3 mg/kg every three weeks. The model was used to predict the percentage of CD19 on blast cells that were bound to SGN-CD19A (CD19 occupancy). High target saturation was assumed to occur if 90% of the CD19 proteins on blasts were occupied.
A simulation was run for an ALL patient with low baseline CD19 expression and 100% bone marrow blasts with blast hypercellularity. As above, SGN-CD19A was administered on a fixed dosage schedules: 1.6 mg/kg on days 1 and 7 of a 21 day cycle; 2.2 mg/kg every two weeks; or 3 mg/kg every three weeks. The model was used to predict the percentage of CD19 on blast cells that were bound to SGN-CD19A (CD19 occupancy). High target saturation was assumed to occur if 90% of the CD19 proteins on blasts were occupied.
The remaining simulations tested more frequent doses or loading doses of SGN-CD19A followed by less frequent and/or lower maintenance doses. A simulation was run for an ALL patient with high baseline CD19 expression and 100% bone marrow blasts and hypercellularity. The dose scenario used 2 mg/kg dose given on days 1 and 8 of a twenty-one day cycle for the entire test period. The other doses started with 2 mg/kg given on days 1 and 8 of a twenty-one day cycle, followed by 2, 1 or 0.5 mg/kg given every three weeks.
A loading dose simulation was run for an ALL patient with high baseline CD19 expression and 100% bone marrow blasts and hypercellularity. This loading dose scenario used 5 mg/kg given on days 1 of a twenty-one day cycle for the entire test period. The other doses started with 5 mg/kg given on days 1 of a twenty-one day cycle, followed by 3, 2, or 1 mg/kg given every three weeks.
A loading dose simulation was run for an ALL patient with low baseline CD19 expression and 100% bone marrow blasts with blast hypercellularity. This dose scenario used 2 mg/kg given on days 1 and 8 of a twenty-one day cycle for the entire test period. The other doses started with 2 mg/kg given on days 1 and 8 of a twenty-one day cycle, followed by 2, 1 or 0.5 mg/kg given every three weeks.
A loading dose simulation was run for an ALL patient with low baseline CD19 expression and 100% bone marrow blasts with blast hypercellularity. This loading dose scenario used 5 mg/kg given on days 1 of a twenty-one day cycle for the entire test period. The other doses started with 5 mg/kg given on days 1 of a twenty-one day cycle, followed by 3, 2, or 1 mg/kg given every three weeks.
It is understood that the examples and embodiments described herein are for illustrative purposes only and that various modifications or changes in light thereof will be suggested to persons skilled in the art and are to be included within the spirit and purview of this application and scope of the appended claims. All publications, patents, and patent applications cited herein are hereby incorporated by reference in their entirety for all purposes.
This application claims priority to, and benefit of, U.S. Provisional Patent Application No. 61/976,790, filed Apr. 8, 2014.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US2015/024732 | 4/7/2015 | WO | 00 |
| Number | Date | Country | |
|---|---|---|---|
| 61976790 | Apr 2014 | US |
