Pharmaceutical formulations of C1 esterase inhibitor

Abstract

The present invention relates to pharmaceutical formulations comprising the C1 esterase inhibitor (C1-INH), exhibiting a higher stability for prolonged storage and a reduced formation of aggregates of said esterase inhibitor (C1-INH) upon storage for ameliorated use in treating or preventing disorders related to kinin formation.

Claims

1. A pharmaceutical formulation comprising (a) C1-INH at a concentration of about 400 IU/mL to 2,000 IU/mL; and (b) histidine or a salt thereof at a concentration of about 5 mM to 150 mM, wherein the formulation does not comprise citrate or phosphate, and wherein the pH of the formulation is between about 6.7 and 7.5.

2. The pharmaceutical formulation according to claim 1, further comprising one or more additional amino acid, or a salt thereof, at a concentration of 2 mM to 150 mM for each amino acid.

3. The pharmaceutical formulation according to claim 2, wherein said one or more additional amino acid comprises one or more of arginine, glycine, lysine, and a salt thereof.

4. The pharmaceutical formulation according to claim 1, further comprising saccharose at a concentration of about 5-250 mM.

5. The pharmaceutical formulation according to claim 1, further comprising sodium chloride or sodium glutamate or both at a concentration of about 1 mM to 200 mM.

6. The pharmaceutical formulation according to claim 1, wherein the formulation comprises (a) about 400 IU/mL to 625 IU/mL C1-INH, (b) about 10 mM to 200 mM sodium chloride, (c) about 5 mM to 150 mM histidine, (d) about 5 mM to 50 mM arginine or arginine*HCl, and (e) about 100 mM to 200 mM saccharose.

7. The pharmaceutical formulation according to claim 1, wherein the formulation further comprises (a) a non-ionic detergent selected from the group consisting of polysorbate 80, polysorbate 20, and a combination thereof; and/or (b) a preservative and/or antioxidant selected from the group consisting of benzyl alcohol, cresol, phenol, methionine glutathione, and a combination thereof.

8. The pharmaceutical formulation according to claim 1, wherein the C1-INH is (a) human C1-INH derived from human plasma or (b) human C1-INH that is recombinantly expressed.

9. The pharmaceutical formulation according to claim 1, wherein the formulation is (a) reconstituted from a lyophilized powder with a suitable liquid, or (b) provided as a liquid formulation.

10. The pharmaceutical formulation according to claim 1, wherein the formulation is provided as a lyophilized powder.

11. The pharmaceutical formulation according to claim 1, formulated for subcutaneous administration or intravenous administration.

12. A method of acute and/or prophylactic treatment of a disease or disorder, comprising administering a pharmaceutically effective amount of the pharmaceutical formulation according to claim 1 to a patient in need thereof, wherein the disease or disorder is a disorder related to kinin formation, a disorder related to ischemia-reperfusion injury (IRI), or retinopathy.

13. A kit comprising the pharmaceutical formulation according to claim 1 as a lyophilized powder and a volume of a suitable liquid for reconstitution.

14. A kit comprising the pharmaceutical formulation according to claim 1 and at least one syringe and/or one needle.

15. A syringe prefilled with a liquid pharmaceutical formulation according to claim 1.

16. The pharmaceutical formulation according to claim 1, further comprising: (a) one or more additional amino acid or a salt thereof, at a concentration of about 5 mM to 50 mM; (b) saccharose at a concentration of about 20 mM to 200 mM; and (c) sodium chloride and/or sodium glutamate at a concentration of about 20 mM to 150 mM; wherein the concentration of histidine, or a salt thereof, is about 10 mM to 80 mM.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) FIG. 1: HMWC levels by SEC HPLC of three C1-INH formulations over 36 months at 2-8° C.:

(2) FIG. 2: HMWC levels by SEC HPLC of three C1-INH formulations over 36 months at 25° C.

(3) FIG. 3: HMWC levels by SEC HPLC of three C1-INH formulations over 18 months at 40° C.

(4) FIG. 4: Relative C1-INH activity of three C1-INH formulations over 36 months at 2-8° C.

(5) FIG. 5: Relative C1-INH activity of three C1-INH formulations over 36 months at 25° C.

(6) FIG. 6: Relative C1-INH activity of three C1-INH formulations over 18 months at 40° C.

(7) FIG. 7: HMWC levels by SEC HPLC of five C1-INH formulations over 24 months at 2-8° C.:

(8) FIG. 8: HMWC levels by SEC HPLC of five C1-INH formulations over 6 months at 40° C.

(9) FIG. 9: Relative C1-INH activity of five C1-INH formulations over 24 months at 2-8° C.

(10) FIG. 10: Relative C1-INH activity of five C1-INH formulations over 6 months at 40° C.

DETAILED DESCRIPTION

Definitions

(11) According to the present invention, the term “C1 esterase inhibitor” or “C1 inhibitor” (“C1-INH”) refers to the proteins or fragments thereof that function as serine protease inhibitors and inhibit proteases associated with the complement system, preferably proteases C1r and C1s as well as MASP-1 and MASP-2, with the kallikrein-kinin system, preferably plasma kallikrein and/or factor XIIa, and with the coagulation system, preferably factor XIa and factor XIIa. In addition, the C1-INH can serve as an anti-inflammatory molecule that reduces the selectin-mediated leukocyte adhesion to endothelial cells. C1-INH as used herein can be the native serine protease inhibitor or an active fragment thereof, or it can comprise a recombinant peptide, a synthetic peptide, peptide mimetic, or peptide fragment that provides similar functional properties, such as the inhibition of proteases C1r and C1 s, and/or MASP-1 and MASP-2, and/or plasma kallikrein, and/or factor XIIa, and/or factor XIa. The term C1-INH shall also encompass all natural occurring alleles, splice variants and isoforms which have the same or similar functions as the C1-INH. For further disclosure regarding the structure and function of C1-INH, see U.S. Pat. Nos. 4,915,945, 5,939,389, 6,248,365, 7,053,176 and WO 2007/073186.

(12) One “unit” (“U”) of C1-INH is equivalent to the C1-INH activity in 1 mL of fresh citrated plasma of healthy donors. The C1-INH may also be determined in “international units” (“IU”). These units are based on the current World Health Organization (WHO) standard for C1-INH concentrates (08/256) which was calibrated in an international collaborative study using normal local human plasma pools. In general, U and IU are equivalent.

(13) The term “hereditary angioedema” (“HAE”) as used herein relates to angioedema caused by a low content and low inhibitory activity of C1-INH in the circulation (HAE type I) or by the presence of normal or elevated antigenic levels of C1-INH of low functional activity (HAE type II). The term “HAE” as used herein also encompasses HAE with normal C1-INH (also known as HAE type III) which has been described recently in two subcategories: (1) HAE due to mutation in the factor XII gene and, as a result, increased activity of factor XII leading to a high generation of bradykinin, and (2) HAE of unknown genetic cause. In patients suffering from hereditary angioedema, edema attacks can occur in various intervals, including a daily, weekly, monthly, or even yearly basis. Furthermore, there are affected patients wherein no edema occurs.

(14) The term “angioedema” (“edema”) as used herein relates to swelling of tissue, for example swelling of skin or mucosa. The swelling can occur, for example, in the face, at hands or feet or on the genitals. Furthermore, swelling can occur in the gastro-intestinal tract or in the respiratory tract. Other organs can also be affected. Swelling persists usually between one and three days. However, remission can already occur after hours or not until weeks.

(15) The term “ischemia-reperfusion injury” (“IRI”) is an injury caused by the return of blood into tissue (“reperfusion”) after an ischemia or a lack of oxygen. Direct damage to the tissue is caused by the interruption of the blood flow, mainly due to loss of oxygenation to the viable tissue, ultimately leading to infarction if not reversed. However, if the insult is reversed, the reperfusion of the ischemic tissue may paradoxically cause further “indirect” damage. Upon long duration of ischemia, the “direct” damage resulting from hypoxia alone is the predominant mechanism. For shorter durations of ischemia, the “indirect” reperfusion mediated damage increasingly contributes to the damage caused.

(16) The term “retinopathy” as used herein relates to acute or persistent damage of the eye. Retinopathy can be caused by diabetes mellitus (leading to diabetic retinopathy), arterial hypertension (leading to hypertensive retinopathy), prematurity of the newborn (leading to retinopathy of prematurity), exposure to ionizing radiation (radiation retinopathy), direct sunlight exposure (solar retinopathy), sickle cell disease, retinal vascular disease such as retinal vein or artery occlusion, trauma, especially to the head and other diseases or conditions. Many types of retinopathy are proliferative resulting, most often, from neovascularization or the overgrowth of blood vessels. Angiogenesis, the sprouting of new vessels is the hallmark precursor that may result in blindness or severe vision loss particularly if the macula becomes affected. In rare cases, retinopathy is caused by genetic diseases.

(17) The term “acute treatment” or “treatment” as used herein relates to the treatment of a patient displaying acute symptoms. Acute treatment can occur from the appearance of the symptom until the full remission of the symptom. An acute treatment can occur once or several times until the desired therapeutic effect is achieved.

(18) The term “prophylactic treatment” or “prophylaxis” or “prevention” as used herein relates to the treatment of a patient in order to prevent the occurrence of symptoms. Prophylactic treatment can occur at regular intervals of days, weeks or months. Prophylactic treatment can also occasionally occur.

(19) The term “about” means within an acceptable error range for a particular value, which partially depends on the limitations of the measurement system.

(20) The term “HMWC” or “high molecular weight components” as used herein refers to any self-associated, i.e. multimerised or aggregated protein species, in particular of C1-INH, with monomer defined as the smallest functional subunit. HMWC are further classified based on five characteristics: size, reversibility/dissociation, conformation, chemical modification, and morphology (Narhi et al., J. Pharm. Sci. 2012, 101(2): 493-498).

(21) HMWC, in particular multimers and aggregates, have been recognized for their potential to elicit immune responses to therapeutic protein products for over a half-century (Gamble, Int. Arch. Allergy Appl. Immunol. 1966, 30(5): 446-455). The underlying mechanisms by which proteins aggregate may elicit or enhance immune responses include inter alia the following: extensive cross-linking of B-cell receptors, causing efficient B-cell activation (Dintzis et al., J. Immunol. 1989, 143(4): 1239-1244; Bachmann et al., Science 1993, 262(5138): 1448-1451); enhancing antigen uptake, processing, and presentation; and triggering immunostimulatory danger signals (Seong and Matzinger, Nat. Rev. Immunol. 2004, 4(6): 469-478). Such mechanisms may enhance recruitment of the T-cell help needed for generation of high-affinity, isotype-switched IgG antibody, whereby the antibody response is most often associated with neutralization of product efficacy (Bachmann and Zinkernagel, Annu. Rev. Immunol. 1997, 15:235-70).

(22) The term “finished dosage form (FDF)” of a drug has undergone all stages of manufacture, including packaging in its final container and labelling.

(23) The term “physiologically acceptable salt” of this invention refers to salts in formulations that are mainly used in treating medical conditions in humans, in particular to treating or preventing disorders related to kinin formation. Further, a physiological acceptable salt refers to ionic substances which are soluble, i.e. in the liquid, preferably aqueous, state a physiological acceptable salt will be present in form of its dissolved cation(s) and anion(s), and which will not cause serious adverse side events after administration to the human body. In this sense, the formulations or their finished dosage forms are appropriate for physiological practice together with other excipients.

(24) The term “WFI” refers to “water for injection”. It is water intended for use in the manufacture of medicines for parenteral administration, the solvent of which is water. Alternatively, it refers to water that is used to dissolve or dilute substances or preparations for parenteral administration.

(25) It is purified by distillation or a purification process, which is equivalent or superior to distillation in the removal of chemicals and microorganisms.

(26) C1 Esterase Inhibitor

(27) In certain embodiments of the invention, the C1-INH is a plasma-derived or a recombinant C1-INH. In further embodiments said inhibitor is identical to the naturally occurring human protein or a variant thereof. In other embodiments, said inhibitor is human C1-INH. In other embodiments, said inhibitor is a recombinant analogue of human C1-INH protein.

(28) According to the present invention, the C1-INH may be modified to improve its bioavailability and/or half-life, to improve its efficacy and/or to reduce its potential side effects. The modification can be introduced during recombinant synthesis or otherwise. Examples for such modifications are glycosylation, PEGylation and HESylation of the C1-INH or an albumin fusion of the described C1-INH. In some embodiments, C1-INH comprises a fusion construct between C1-INH and albumin, in particular human albumin. In some embodiments, the albumin is a recombinant protein. In certain embodiments, the C1-INH and albumin proteins are joined directly, or via a linker polypeptide. For further disclosure regarding glycosylation and albumin fusion of proteins, see WO 01/79271.

(29) Preparation of C1-INH

(30) For the purpose of this invention, the C1-INH can be produced according to methods known to the skilled person. For example, plasma-derived C1-INH can be prepared by collecting blood plasma from several donors. Donors of plasma should be healthy as defined in the art. Preferably, the plasma of several (1000 or more) healthy donors is pooled and optionally further processed. An exemplary process for preparing C1-INH for therapeutic purposes is disclosed in U.S. Pat. No. 4,915,945. Alternatively, in other embodiments, C1-INH can be collected and concentrated from natural tissue sources using techniques known in the art. Recombinant C1-INH can be prepared by known methods.

(31) In certain embodiments, C1-INH is derived from human plasma. In a further preferred embodiment, C1-INH is prepared by recombinant expression.

(32) A commercially available product comprising C1-INH is, e.g., plasma-derived Berinert® (CSL Behring). Berinert® is manufactured according to A. Feussner et al. (Transfusion 2014, 54: 2566-73) and is indicated for treatment of hereditary angioedema and congenital deficiencies. Alternative commercially available products comprising C1-INH are plasma-derived Cetor® (Sanquin), Cinryze® (Shire), and recombinant Ruconest®/Rhucin® (Pharming).

(33) C1-INH Formulations

(34) The present invention relates to formulations comprising C1-INH. These highly concentrated formulations of the invention are provided in low volume formulations having a long-term stability. The formulations are well-tolerated and suitable for intravenous and in particular subcutaneous administration.

(35) The concentration of C1-INH in said formulations is about 400 IU/mL to 2,000 IU/mL, preferably of about 400 IU/mL to 1,200 IU/mL, more preferably of about 400 IU/mL to 1000 IU/mL, more preferably of about 400 IU/mL to 800 IU/mL, more preferably of about 400 IU/mL to 625 IU/mL, and most preferably of about 500 IU/mL or any range in between.

(36) Said pharmaceutical formulations of the present invention further comprise histidine, preferably L-histidine, or a salt/salts thereof at a concentration of about 5-150 mM, preferably 10-80 mM. Additionally said formulation neither comprises sodium citrate nor sodium di-hydrogen phosphate/di-sodium hydrogen phosphate as buffer substances.

(37) In preferred embodiments, said formulation further comprises one or more amino acids or a salt/salts thereof. In certain embodiments the one or more amino acids are selected from arginine, glycin and/or lysine. The amino acids may be L- or D-amino acids, preferably L-amino acids. The concentration of each further amino acid of this invention ranges from about 2 mM to about 150 mM, preferably from about 3 mM to about 130 mM, more preferably from about 5 mM to about 50 mM.

(38) In certain embodiments the pharmaceutical formulation comprises only one type of further amino acid.

(39) In certain embodiments, the formulations referred to herein do not comprise a buffer compound selected from the following: succinate, tartrate, maleate, acetate, and salts thereof.

(40) In further embodiments, the formulation comprises saccharose, trehalose, or a combination thereof at a concentration of about 5-250 mM, preferably at a concentration of about 20-200 mM, more preferably at a concentration of about 100-200 mM. In highly preferred embodiments, the concentration is about 140-160 mM.

(41) In various embodiments, the pharmaceutical formulation further comprises at least one substance selected from the group consisting of sodium chloride, di-sodium EDTA, sodium acetate, sodium glutamate and sodium succinate at a concentration of about 1-200 mM, preferably of about 10-200 mM, more preferably of about 20-150 mM, and even more preferably of about 40-60 mM or about 130-150 mM.

(42) In certain embodiments the pharmaceutical formulation does not comprise a tissue permability enhancer, such as e.g. hyaluronidase.

(43) In some embodiments, the pH of the formulation is between about 6.0 and 8.0, between about 6.7 and 7.5, between about 6.8 and 7.4, between about 6.9 and 7.3, between about 7.0 and 7.2. In the most preferred embodiment, the pH of the formulation is 7.0.

(44) In some embodiments, the pharmaceutical formulation comprises (a) C1-INH; (b) sodium chloride; (c) histidine; and (d) saccharose.

(45) In certain embodiments, the pharmaceutical formulation comprises (a) about 400-625 IU/mL C1-INH; (b) about 20-200 mM sodium chloride; (c) about 10-90 mM histidine; and (d) about 100-200 mM saccharose.

(46) In other embodiments, the pharmaceutical formulation comprises (a) C1-INH; (b) sodium chloride; (c) histidine; (d) arginine or arginine*HCl; and (d) saccharose.

(47) In certain embodiments, the pharmaceutical formulation comprises (a) about 400-625 IU/mL C1-INH; (b) about 20-200 mM sodium chloride; (c) about 5-150 mM histidine; (d) about 5-50 mM arginine or arginine*HCl; and (e) about 100-200 mM saccharose.

(48) In preferred embodiments, the pharmaceutical formulation comprises: (a) about 400-625 IU/mL C1-INH; (b) about 25-70 mM sodium chloride; (c) about 20-80 mM histidine; (d) about 5-30 mM arginine or arginine*HCl; and (e) about 120-160 mM saccharose.

(49) In more preferred embodiments, the pharmaceutical formulation comprises: (a) about 400-625 IU/mL C1-INH; (b) about 30-60 mM sodium chloride; (c) about 60-70 mM histidine; (d) about 10-20 mM arginine or arginine*HCl; and (e) about 120-160 mM saccharose.

(50) In even more preferred embodiments, the pharmaceutical formulation comprises: (a) about 400-625 IU/mL C1-INH; (b) about 40-50 mM sodium chloride; (c) about 60-70 mM histidine; (d) about 10-15 mM arginine or arginine*HCl; and (e) about 140-150 mM saccharose.

(51) In further embodiments, the provided formulation comprises one or more detergents and/or one or more preservatives and/or one or more antioxidants.

(52) In certain embodiments, the pharmaceutical formulation can comprise PS80 (polysorbate 80) and/or PS20 (polysorbate 20). In the pharmaceutical formulation, PS80 may be present at a concentration of about 0.5-2 mg/mL. In the pharmaceutical formulation, PS20 may be present at a concentration of about 0.5-2 mg/mL.

(53) In certain embodiments, the preservatives and/or antioxidants are selected from the group consisting of benzylalcohol, cresol, phenol, methionine and glutathione. In the pharmaceutical formulation the preservatives and/or antioxidants may be present at a concentration of about 1-5 mM.

(54) The provided formulations may comprise pharmaceutical carriers and excipients that are well known in the art (see for example “Pharmaceutical Formulation Development of Peptides and Proteins”, Frokjaer et al., Taylor & Francis 2000 or “Handbook of Pharmaceutical Excipients”, 3.sup.rd edition, Kibbe et al., Pharmaceutical Press 2000).

(55) In one embodiment, the formulation comprises an absolute amount of C1-INH of about 1,000 IU/FDF, 1,200 IU/FDF, about 1,500 IU/FDF, about 1,800 IU/FDF, about 2,100 IU/FDF, about 2,400 IU/FDF, about 2,700 IU/FDF or about 3,000 IU/FDF or any absolute amount in between. In preferred embodiments, the formulation comprises an absolute amount of C1-INH of at least 1,200 IU per FDF, 1,500 IU per FDF, or at least 1,800 IU per FDF.

(56) In one embodiment, the formulation comprises an absolute amount of C1-INH of about 1,200 IU-3,000 IU, of about 1,200 IU-2,000 IU, of about 1,200 IU-1,800 IU or of about 1,400 IU-1,600 IU.

(57) In one embodiment, the liquid pharmaceutical formulation is provided in a volume of about 0.1-10 mL/FDF, about 1-5 mL/FDF or about 3 mL/FDF or any volume in between. In preferred embodiments, the formulation is provided as an aqueous solution in a volume of about 3 mL per FDF, of about 4 mL per FDF or of about 6 mL per FDF.

(58) In some embodiments, the C1-INH is human C1-INH. In certain embodiments the human C1-INH is derived from human plasma, or the human C1-INH is recombinantly expressed. Preferably, the C1-INH is derived from human plasma.

(59) In various embodiments, the pharmaceutical formulations of the invention comprises less than 10% of HMWC, preferably less than 8% of HMWC, more preferably less than 5% of HMWC or even more preferably less than 3% of HMWC as determined immediately by SEC-HPLC. Immediately after preparation means within one day after preparation.

(60) In some embodiments, the formulation is provided as a stable lyophilized powder. The formulation may be lyophilized by a variety of procedures known in the art. The lyophilized powder can be reconstituted with a respective volume of a suitable liquid to obtain the pharmaceutical liquid formulation for injection. Suitable liquids are, e.g., water for injection (WFI).

(61) In alternative embodiments, the formulation is provided as a stable liquid formulation. In one embodiment, the liquid formulation is obtainable by reconstitution of a stable lyophilized powder with a suitable liquid.

(62) In other words, in various embodiments, the components of the pharmaceutical formulation are present in a solution suitable for injection without any further processing, i.e. the formulation is provided as a stable liquid formulation. Alternatively, the components are provided as a stable lyophilized powder and the indicated concentrations are reached upon reconstitution of the lyophilized powder in the respective volume of a suitable liquid. A suitable liquid for reconstitution is e.g. water for injection (WFI).

(63) The terms “stable formulation”, “stable lyophilized powder”, “stable lyophilized formulation” or “stable liquid formulation” as used herein refer to pharmaceutical formulations wherein no significant decrease of C1-INH activity is observed after a certain period of time of storage at least at 2-8° C., preferably at about 25° C. The term “no significant decrease of C1-INH activity” means at least 70%, 75%, 80%, 85%, 90%, 95% 96%, 97%, 98%, 99% of the C1-INH activity of the original C1-INH activity. The term “C1-INH activity” refers to the inhibitory activity of the C1-INH protein in plasma and is indicated in “IU/mL” and can be measured without limitation e.g. by a chromogenic assay (see e.g. example 1).

(64) In alternative embodiments, the terms “stable formulation”, “stable lyophilized powder”, “stable lyophilized formulation” or “stable liquid formulation” as used herein refer to formulations wherein no significant increase of HMWC formation is observed after a certain period of time, preferably at least 36 months, of storage at 2-8° C., preferably at about 25° C. The term “no significant increase of HMWC formation” means at most 20%, 15%, 14%, 13%, 12%, 11% 10%, 9%, 8%, 7%, 6%, 5%, 4%, or about 3% protein HMWC at a certain point in time, e.g. after 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 11, 12, 15, 18, 21, 24, or 36 months, i.e. the percentage of HMWC is determined as the percentage of HMWC of the total protein content in the formulation at this certain point of time and this value is at the most 20%, 15%, 14%, 13%, 12%, 11% 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%. The level of protein HMWC of the total protein can be measured without limitation e.g. by SEC HPLC (see e.g. example 1).

(65) In further alternative embodiments the terms “stable formulation”, “stable lyophilized powder”, “stable lyophilized formulation” or “stable liquid formulation” as used herein refer to formulations wherein no significant increase of HMWC formation is observed after a certain period of time, preferably at least 18-24 months, of storage at about 40° C. The term “no significant increase of HMWC formation” means formation of at most 20%, 15%, 14%, 13%, 12%, 11% 10%, 9%, 8%, 7%, 6%, 5%, or about 4% protein HMWC at a certain point in time, e.g. after 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 11, 12, 15, 18, 21, or 24 months, i.e. the percentage of HMWC is determined as the percentage of HMWC of the total protein content in the formulation at this certain point of time and this value is at the most 20%, 15%, 14%, 13%, 12%, 11% 10%, 9%, 8%, 7%, 6%, 5%, 4%. The level of protein HMWC of the total protein can be measured without limitation e.g. by SEC HPLC (see e.g. example 1).

(66) In alternative embodiments, the terms “stable formulation”, “stable lyophilized powder”, “stable lyophilized formulation” or “stable liquid formulation” as used herein refer to formulations wherein no significant increase of fragmentation is observed after a certain period of time, preferably at least 36 months, of storage at 2-8° C., preferably at about 25° C. The term “no significant increase of fragmentation” means at most 20%, 15%, 14%, 13%, 12%, 11% 10%, 9%, 8%, 7%, 6%, 5%, 4%, or about 3% fragments at a certain point in time, e.g. after 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 11, 12, 15, 18, 21, 24, or 36 months, i.e. the percentage of fragments is determined as the percentage of fragments the total protein content in the formulation at this certain point of time and this value is at the most 20%, 15%, 14%, 13%, 12%, 11% 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%. The level of fragments of the total protein can be measured without limitation e.g. by SEC HPLC.

(67) In a series of embodiments, the formulations provided herein upon lyophilization will be stable for a certain period of time, i.e. for 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 or more months at a temperature of 25° C. In a preferred embodiment, the lyophilized formulation will be stable for at least 6 months (25° C.). In a more preferred embodiment, the lyophilized formulation will be stable for at least 12 months (25° C.). In another preferred embodiment, the lyophilized formulation will be stable for at least 24 months (25° C.).

(68) In another series of embodiments, the liquid formulation provided herein will be stable for a certain period of time, i.e. for 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 or more months at a temperature of 2-8° C. In a preferred embodiment, the liquid formulation will be stable for at least 6 months (2-8° C.). In a more preferred embodiment, the liquid formulation will be stable for at least 12 months (2-8° C.). In another preferred embodiment, the liquid formulation will be stable for at least 24 months (2-8° C.).

(69) In another series of embodiments, the liquid formulation provided herein will be stable for a certain period of time, i.e. for 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 or more months at a temperature of 25° C. In a preferred embodiment, the liquid formulation will be stable for at least 6 months (25° C.). In a more preferred embodiment, the liquid formulation will be stable for at least 12 months (25° C.).

(70) In certain embodiments, the provided formulations retain at least 70%, preferably at least 80%, more preferably at least 90% and most preferably at least 95% C1-INH activity after 12 months, preferably after 24 months, more preferably after 36 months and most preferably after 48 months of storage at 2-8° C.

(71) In certain embodiments, the provided formulation retains at least 70%, preferably at least 80%, more preferably at least 90% and most preferably at least 95% C1-INH activity after 6 months, preferably after 12 months, more preferably after 24 months and most preferably after 36 months of storage at 25° C.

(72) In certain embodiments, the provided formulation retains at least 30%, preferably at least 40%, more preferably at least 50% and most preferably at least 60% C1-INH activity after 6 month, preferably after 12 months, more preferably after 24 months of storage at 40° C.

(73) Hence, the provided pharmaceutical formulations can be utilized as stand-by medication, i.e., a patient suffering from hereditary angioedema can always keep such a formulation in close proximity (without the requirement of cooling) in order to have an immediate treatment available upon occurrence of an edema attack. Moreover, the provided pharmaceutical formulations demonstrate a long-term stability compared to concentrated C1-INH formulations having only a buffer excipient in low concentrations.

(74) The provided pharmaceutical formulations are suitable for subcutaneous administration as well as intravenous administration. In general, subcutaneous administration is preferred upon prophylactic treatment of patients suffering from hereditary angioedema and intravenous administration is preferred upon acute treatment of patients suffering from hereditary angioedema. Neither the intravenous nor the subcutaneous administration of the provided pharmaceutical formulations causes serious drug-related adverse side events but only minor treatment-emergent adverse effects. Hence, the provided formulations can be used for both administrations. In further embodiments, the pharmaceutical formulation described herein is suitable for intra-arterial and/or intramuscular administration.

(75) Moreover, the patients can self-administer the provided formulations.

(76) Patients can use the provided formulations for prophylactic treatment and, in addition, the same formulation can be used for an acute treatment upon occurrence of an angioedema attack. Hence, patients are only supplied with one type of formulation, which is indicative of a high patient compliance and which can be used as required. For these reasons, the provided formulations may achieve a high patient compliance.

(77) Furthermore, the provided formulations exhibit a high local tolerance upon subcutaneous and intravenous injection; they are well tolerated, with no serious drug-related adverse events. In particular, the subcutaneous administration of the provided formulations is safe and well tolerated with only mild-to-moderate local site reactions. Likewise, a high local tolerance is achieved upon intra-arterial injection and intramuscular injection.

(78) Upon administration of the described formulations, no immune reaction directed against the formulation can be observed in the patient after 1, 6, 12, 24, 48 or 72 hours from the time point of administration.

(79) Moreover, thrombotic events, clot formation, thromboembolic complications do not occur after administration of the described formulations in any of the described doses in a patient. Further, administration of the described formulations does not enhance the thrombogenic risk in a patient.

(80) The pharmaceutical formulations of the present invention ensure a good bioavailability of the C1-INH upon subcutaneous as well as upon intravenous administration.

(81) Moreover, periodic subcutaneous administration of the provided formulations leads to a dose-dependent increase in functional C1-INH activity, which would have a clinically meaningful effect in preventing HAE attacks. Upon subcutaneous administration of the provided formulations, C1-INH functional activity time profiles with a considerably lower peak-to-trough ratio and more consistent exposures after subcutaneous administration are achieved. These lower peak-to-trough fluctuations for the subcutaneous administration are particularly desired upon prophylactic treatment, as such plasma levels ensure persistent protection from the occurrence of angioedema attacks in patients suffering from hereditary angioedema.

(82) In another aspect, a kit is provided comprising a lyophilized formulation described herein and the respective amount of a liquid suitable for reconstitution. In certain embodiments, the suitable liquid is water for injection, preferable deionized sterile water for injection.

(83) In some embodiments, the kit can additionally comprise a syringe. In certain embodiments, the syringe is suitable for subcutaneous injection. In other embodiments, the syringe is suitable for intravenous injection. In alternative embodiments, the syringe is suitable for subcutaneous injection and intravenous injection. In further embodiments, the syringe is suitable for intra-arterial injection and/or intramuscular injection.

(84) In some embodiments, the kit further can comprise a needle suitable for intravenous injection and/or a needle suitable for subcutaneous injection. In a further embodiment, the kit can comprise a needle suitable for intra-arterial injection and/or a needle suitable for intramuscular injection.

(85) In another aspect, a syringe prefilled with the liquid formulation described herein is provided. In certain embodiments, the syringe is suitable for subcutaneous injection. In other embodiments, the syringe is suitable for intravenous injection. In alternative embodiments, the syringe is suitable for subcutaneous injection and intravenous injection. In further embodiments, the syringe is suitable for intra-arterial injection and/or intramuscular injection.

(86) In another aspect of the invention a method of reconstituting a lyophilized formulation comprising C1-INH in a suitable solution is provided herein. Furthermore, a method for reconstituting any of the lyophilized formulations described herein is provided.

(87) In some embodiments, the use of a lyophilized formulation comprising C1-INH for the preparation of a liquid formulation comprising C1-INH is provided. The lyophilized formulation may be any lyophilized formulation described herein.

(88) Methods and Uses

(89) The provided formulations can be used in the treatment of various diseases and conditions.

(90) In some embodiments, the provided formulations can be used in the treatment and/or prevention of a disorder related to kinin formation, in particular hereditary angioedema (HAE), secondary brain edema, edema of the central nervous system, hypotensive shock, or edema during or after contacting blood with an artificial surface.

(91) Further provided is a method of treating or preventing a disorder related to kinin formation, in particular hereditary angioedema (HAE), secondary brain edema, edema of the central nervous system, hypotensive shock, or edema during or after contacting blood with an artificial surface in a patient, comprising administering a pharmaceutically effective dose of any of the formulations described herein.

(92) In certain embodiments, the provided formulations are used in the treatment and/or prophylaxis of hereditary angioedema, in particular HAE type I, HAE type II and/or HAE type III.

(93) In certain embodiments, a method of treating or preventing hereditary angioedema, in particular HAE type I, HAE type II and/or HAE type III in a patient, comprising administering a pharmaceutically effective dose of any of the formulations described herein, is provided.

(94) In further embodiments, the provided formulations can be used in the treatment and/or prophylaxis of an ischemia-reperfusion injury (IRI), in particular wherein the IRI is due to surgical intervention, in particular vascular surgery, cardiac surgery, neurosurgery, trauma surgery, cancer surgery, orthopedic surgery, transplantation, minimally invasive surgery, or insertion of a device for delivery of a pharmacologically active substance or for mechanical removal of complete or partial obstructions.

(95) Further provided is a method of treating or preventing an ischemia-reperfusion injury (IRI), in particular wherein the IRI is due to surgical intervention, in particular vascular surgery, cardiac surgery, neurosurgery, trauma surgery, cancer surgery, orthopedic surgery, transplantation, minimally invasive surgery, or insertion of a device for delivery of a pharmacologically active substance or for mechanical removal of complete or partial obstructions in a patient, comprising administering a pharmaceutically effective dose of any of the formulations described herein.

(96) In some embodiments, the provided formulations can be used to prevent rejection of a transplanted tissue in a patient. The transplantation can be allotransplantation or xenotransplantation.

(97) Further provided is a method of preventing rejection of a transplanted tissue in a patient, comprising administering a pharmaceutically effective dose of any of the formulations described herein. The transplantation can be allotransplantation or xenotransplantation.

(98) In further embodiments, the provided formulations can be used in the treatment and/or prevention of retinopathy.

(99) Further provided is a method of treating or preventing retinopathy in a patient, comprising administering a pharmaceutically effective dose of any of the formulations described herein

(100) Treatment and Administration

(101) In various embodiments, acute treatment occurs upon treatment of a patient having hereditary angioedema and suffering from an acute angioedema attack.

(102) In further embodiments, prophylactic treatment of a patient having hereditary angioedema occurs in order to prevent the occurrence of angioedema. Prophylactic treatment of patients suffering from hereditary angioedema can be done regularly and can also occur occasionally, for example before surgical interventions, dental treatments and other symptom-triggering situations such as a situation where a patient realizes an upcoming edema.

(103) In various embodiments, the provided formulations can be administered via subcutaneous injection. In alternative embodiments, the provided formulations can be administered via intravenous injection. The formulations can be administered continuously by infusion or by bolus injection. In a preferred embodiment, the provided formulations can be administered via subcutaneous injection and via intravenous injection. In a further preferred embodiment, the patient can self-administer the provided formulations.

(104) In some embodiments, the provided formulation is administered via intravenous injection during acute treatment of a patient. In other embodiments, the provided formulation is administered via subcutaneous injection during prophylactic treatment of a patient.

(105) In further embodiments, the provided formulations can be administered via intra-arterial injection. In further embodiments, the provided formulations can be administered via intramuscular injection.

(106) In further embodiments, the formulations described herein may be administered to a patient by any pharmaceutically suitable means of administration. Various delivery systems are known and can be used to administer the composition by any convenient route. Preferentially the compositions of the invention are administered systemically. For systemic use, the therapeutic proteins of the invention are formulated for parenteral (e.g. intravenous, subcutaneous, intramuscular, intraperitoneal, intracerebral, intrapulmonar, intranasal or transdermal) or enteral (e.g., oral, vaginal or rectal) delivery according to conventional methods. Some formulations encompass slow release systems.

(107) Dosing Schemes

(108) In one embodiment, a dose of C1-INH of about 1,200 IU, about 1,500 IU, about 1,600 IU, about 1,700 IU, about 1,800 IU, about 1,900 IU, about 2,000 IU, about 2,100 IU, about 2,200 IU, about 2,300 IU, about 2,400 IU, about 2,500 IU, about 2,600 IU, about 2,700 IU, about 2,800 IU, about 2,900 IU, about 3,000 IU, about 3,500 IU, about 4,000 IU, about 4,500 IU, about 5,000 IU, about 5,500 IU or about 6,000 IU or any amount in between is administered to a patient. In a preferred embodiment, a dose of about 1,500 IU, about 2,000 IU, about 3,000 IU, about 4,000 IU, about 5,000 IU or about 6,000 IU is administered to a patient.

(109) In further embodiments, a dose of C1-INH of about 10-100 IU/kg bodyweight, of about 20-90 IU/kg bodyweight, of about 20-80 IU/kg bodyweight, of about 30-70 IU/kg bodyweight, of about 40-60 IU/kg bodyweight or any range in between is administered to a patient.

(110) In certain embodiments, upon subcutaneous administration a dose of C1-INH of about 20-80 IU/kg bodyweight, of about 30-80 IU/kg bodyweight, of about 40-80 IU/kg bodyweight, of about 40-60 IU/kg bodyweight, of about 50-60 IU/kg bodyweight or any range in between is administered to a patient.

(111) In certain embodiments, upon intravenous administration, preferably in the acute treatment, a dose of C1-INH of about 10-60 IU/kg bodyweight, of about 20-40 IU/kg bodyweight, of about 20 IU/kg bodyweight or any range in between is administered to a patient.

(112) In certain embodiments the target is to reach a mean C1-INH activity level in the prophylactic treatment.

(113) In various embodiments, a dose of C1-INH is administered, preferably in prophylactic treatment, at intervals of 1, 2, 3, 4, 5, 6 or 7 days. In a further embodiment, a dose of C1-INH is administered, preferably in prophylactic treatment, at intervals of every 1-2 days, at intervals of every 2-3 days, at intervals of every 3-4 days, at intervals of every 4-5 days, at intervals of every 5-6 days or at intervals of every 6-7 days.

(114) In some embodiments, a formulation comprising one, two or more FDF(s) of about 1,500 IU of C1-INH is/are administered, preferably subcutaneously, at intervals of every 2-3 days.

(115) In further embodiment, a formulation comprising one, two or more FDF(s) of about 3,000 IU of C1-INH is/are administered, preferably subcutaneously, at intervals of every 3-4 days.

(116) In further embodiments, a formulation comprising about 1,500 IU, about 3,000 IU, about 4,000 IU, about 5,000 IU or about 6,000 IU of C1-INH is/are administered, preferably subcutaneously, weekly.

(117) In further embodiments, a formulation comprising about 1,500 IU, about 3,000 IU, about 4,000 IU, about 5,000 IU or about 6,000 IU of C1-INH is/are administered, preferably subcutaneously, twice-weekly.

(118) In other embodiments, a formulation comprising a dose of about 20-80 IU per kg bodyweight, preferably about 20-40 IU C1-INH per kg bodyweight is administered, preferably subcutaneously, at intervals of every 2-3 days.

(119) In further embodiments, a formulation comprising a dose of about 40-60 IU C1-INH per kg bodyweight is administered, preferably subcutaneously, at intervals of every 3-4 days.

(120) In further embodiments, a formulation comprising a dose of about 40-80 IU C1-INH per kg bodyweight or of about 40-60 IU C1-INH per kg bodyweight is administered, preferably subcutaneously, weekly.

(121) In further embodiments, a formulation comprising a dose of about 40-80 IU C1-INH per kg bodyweight or of about 40-60 IU C1-INH per kg bodyweight is administered, preferably subcutaneously, twice weekly.

(122) In other embodiments, one, two or more FDF(s) of about 1,500 IU C1-INH is/are administered to a patient during acute treatment, preferably via intravenous administration. In a further embodiment, one or more FDF(s) of about 3,000 IU C1-INH is/are administered to a patient during acute treatment, preferably via intravenous administration.

(123) In further embodiments, one, two or more dose(s) of about 20 IU C1-INH per kg bodyweight is/are administered to a patient during acute treatment, preferably via intravenous administration. In a further embodiment, one or more dose(s) of about 40 IU C1-INH per kg bodyweight is/are administered to a patient during acute treatment, preferably via intravenous administration.

(124) The examples illustrate the present invention while in no way limiting it.

Example 1

(125) Freeze dried C1-INH concentrate (manufactured based on the Berinert® manufacturing process (according to A. Feussner et al., Transfusion 2014, 54: 2566-73)) was dissolved in WFI. PD10 desalting columns (GE Healthcare) were equilibrated with the target formulation buffer. Then the C1-INH solutions were applied per PD10 column. C1-INH was eluted with the corresponding formulation buffer (see Tables 1 and 2) within the column exclusion volume. C1-INH concentration was determined by chromogenic assay (Berichrom C1-Inhibitor, Siemens) and adjusted to 500 IU/ml using the corresponding formulation buffer. Formulated C1-INH was filtered through 0.2 μm and then dispensed in aliquots to glass vials, lyophilized and then stoppered with rubber stoppers under aseptic conditions. This was done for each of the different C1-INH formulations disclosed in Table 1 and 2. The respective glass vials were finally transferred to tempered rooms at 2-8° C., 25° C. or 40° C. (Table 1) and 2-8° C. or 40° C. (Table 2). Sample vials of each C1-INH formulation were taken at various time points and tested for C1-INH activity by chromogenic assay and for HMWC formation and fragmentation by SEC HPLC on a TSK-Gel G3000SWXL (Tosoh) using 20 mM NaH.sub.2PO.sub.4, 20 mM Na.sub.2HPO.sub.4, 100 mM NaCl, pH 7.2 as eluent buffer (see FIGS. 1 to 10).

(126) TABLE-US-00001 TABLE 1 C1-INH formulations A, B, and C. Formulation A B C C1-INH [IU/mL]* 500 500 500 NaCl [g/L] 8.5 4.0 2.5 (~43 mM) Glycin [g/L] 10.0 10.0 — Na.sub.3citrat*2H.sub.2O [g/L] 3.5 3.5 — Histidin [g/L] — — 10.0 (~65 mM) Arginin*HCl [g/L] — — 2.0 (~12 mM) Saccharose [g/L] — — 50.0 (~146 mM) pH 7.0 7.0 7.0 Resid. Moisture [%] 0.21 0.18 0.16 *C1-INH concentration after reconstitution of the respective formulation with 1 mL WFI

(127) Results of the formulations A to C of Table 1 are demonstrated in FIGS. 1 to 6. These data indicate for the formulation C the best C1-INH activity conservation and the lowest HMWC formation.

(128) TABLE-US-00002 TABLE 2 C1-INH formulations 1 to 5. Formulation 1 2 3 4 5 C1-INH [IU/mL]* 500    500    500   500    500   NaCl [g/L] 8.5 8.5 — — — (~145 mM) (~145 mM) Glycin [g/L] 10.0  10.0  — — — (~133 mM) (~133 mM) Histidin [g/L] 2.0 2.0 10.0 10.0  10.0  (~13 mM)  (~13 mM)  (~65 mM) (~65 mM)  (~65 mM) Arginin*HCl [g/L] — — — 2.0 — (~12 mM) Saccharose [g/L] — — 50.0 50.0  50.0 (~146 mM) (~146 mM)  (~146 mM) pH 7.0 8.0  7.0 7.0  8.0 *C1-INH concentration after reconstitution of the respective formulation with 1 mL WFI

(129) Results of the formulations shown in Table 2 are demonstrated in FIGS. 7 to 10. These data indicate for all five formulations acceptable long term stabilities.