Method of Treatment

Abstract

The present invention relates to methods of treating or preventing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA) in a subject, which comprises administering to the subject a therapeutically or prophylactically effective amount of an agent which is a protein comprising amino acids 19 to 168 of the amino acid sequence in FIG. 2 (SEQ ID NO: 2) or a functional equivalent of this protein. Said protein of FIG. 2 of the present application has been designated in the prior art as Coversin, Nomacopan, EV576 or OmCI protein. Alternatively the agent is a nucleic acid molecule encoding a protein comprising amino acids 19 to 168 of the amino acid sequence in FIG. 2 (SEQ ID NO: 2) or a functional equivalent of this protein.

Claims

1. A method of treating or preventing a hematopoietic stem cell transplant associated thrombotic microangiopathy (HSCT-TMA) in a subject, which comprises administering to the subject a therapeutically or prophylactically effective amount of an agent which is a protein comprising amino acids 19 to 168 of the amino acid sequence in FIG. 2 (SEQ ID NO: 2) or a functional equivalent of this protein.

2. An agent which is a protein comprising amino acids 19 to 168 of the amino acid sequence in FIG. 2 (SEQ ID NO: 2) or a functional equivalent of this protein for use in a method of treating or preventing HSCT-TMA in a subject.

3. A method of treating or preventing HSCT-TMA in a subject, which comprises administering to the subject a therapeutically or prophylactically effective amount of an, agent which is a nucleic acid molecule encoding a protein comprising amino acids 19 to 168 of the amino acid sequence in FIG. 2 (SEQ ID NO: 2) or a functional equivalent of this protein.

4. An agent which is a nucleic acid molecule encoding a protein comprising amino acids 19 to 168 of the amino acid sequence in FIG. 2 (SEQ ID NO: 2) or a functional equivalent of this protein for use in a method of treating or preventing HSCT-TMA in a subject

5. The method of any one of claim 1 or 3 or the agent for use of any one of claim 2, or 4, wherein the agent is, or encodes, a protein comprising a sequence having at least 90% sequence identity to the sequence of amino acids 19 to 168 of SEQ ID NO: 2, and said protein binds C5 to prevent the cleavage of complement C5 by convertase into complement C5a and complement C5b and binds to LTB4.

6. The method of any one of claim 1, 3 or 5 or the agent for use of any one of claim 2, 4 or 5, wherein the agent is, or encodes, a protein comprising a sequence having at least 95% sequence identity to the sequence of amino acids 19 to 168 of SEQ ID NO: 2, and said protein binds C5 to prevent the cleavage of complement C5 by convertase into complement C5a and complement C5b and binds to LTB4.

7. The method of any one of claims 1, 3 or 5 to 6, or the agent for use of any one of claims 2, 4 or 5 to 6, wherein the agent is, or encodes, a protein comprising or consisting of the sequence of amino acids 19 to 168 of SEQ ID NO: 2.

8. The method of any one of claim 1 or 3, or the agent for use of any one of claim 2 or 4, wherein agent is, or encodes, a protein comprising the sequence of amino acids 19 to 168 of SEQ ID NO: 2, in which up to 50 amino acid substitutions, insertions or deletions have been made, and the protein binds C5 to prevent the cleavage of complement C5 by convertase into complement C5a and complement C5b and binds to LTB4, wherein each of the six cysteine amino acids at positions 6, 38, 100, 128, 129, 150 of the mature nomacopan molecule as set out in SEQ ID NO: 4 is retained and at least five, ten or fifteen or each of the LTB4 binding residues and at least five, ten or fifteen or twenty or each of C5 binding residues set is retained or is subject to a conservative modification, wherein the LTB4 binding residues are Phe18, Tyr25, Arg36, Leu39, Gly41, Pro43, Leu52, Va154, Met56, Phe58, Thr67, Trp69, Phe71, Gln87, Arg89, His99, His101, Asp103, and Trp115 (numbering according to SEQ ID NO:4) and the C5 binding residues are Va126, Va128, Arg29, Ala44, Gly45, Gly61, Thr62, Ser97, His99, His101, Met 114, Met 116, Leu117, Asp118, Ala119, Glyl20, Glyl21, Leu122, Glu123, Va1124, Glu125, Glu127, His146, Leu147 and Asp 149 (numbering according to SEQ ID NO:4).

9. The method or agent for use of claim 8 wherein up to 2, 3, 4, 5, 10, 15, 20 of the LTB4 and C5 binding residues are subject to a conservative modification.

10. The method or agent for use of claim 8 or 9 wherein at least five, ten or fifteen or each of the LTB4 binding residues and at least five, ten or fifteen or twenty or each of C5 binding residues is retained.

11. The method or agent for use of any of claims 8 to 10 wherein each of the LTB4 binding residues and each of C5 binding residues is retained or is subject to a conservative modification.

12. The method or agent for use of any of claims 8 to 11 wherein each of the LTB4 binding residues and each of C5 binding residues is retained or is subject to a conservative modification, wherein up to 2, 3, 4, 5, 10, 15, 20 of the C5 and/or LTB4 binding residues are subject to a conservative modification.

13. The method or agent for use of any of claims 8 to 12, wherein each of the LTB4 binding residues and each of C5 binding residues is retained.

14. The method of any one of claim 1 or 3, or the agent for use of any one of claim 2 or 4, wherein the agent is, or encodes, a fragment of the protein as defined in any of the preceding claims, and the protein binds C5 to prevent the cleavage of complement C5 by convertase into complement C5a and complement C5b and binds to LTB4.

15. The method or the agent for use of any preceding claim, wherein the agent is administered subcutaneously or intrasynovially, preferably subcutaneously.

16. The method or the agent for use of any preceding claim, wherein the subject is a human.

17. The method or the agent for use of any preceding claim, wherein the method further comprises treating GVHD in the subject.

18. The method or the agent for use of claim 17, wherein the GVHD is acute GVHD.

19. The method or agent for use of any preceding claim, wherein there the method comprises administering to the subject an initial ablating regimen of the agent and then administering maintenance doses of the agent, optionally wherein there is an initial maintenance dose and one or more further maintenance doses.

20. The method or the agent for use of any preceding claim, wherein the method further comprises the administration of a second HSCT-TMA treatment.

21. The method or the agent for use of claim 20, wherein the second HSCT-TMA treatment is selected from (i) a second complement inhibitor; (ii) dose reduction or complete withdrawl of calcineurin inhibitors; (iii) plasma exchange; (iv) an anti-CD20 antibody; (v) an anti-CD25 antibody; (vi) defibrotide; (vii) a vinca alkaloid, such as vincristine and (viii) a statin.

22. The method or the agent for use of claim 21 wherein: (a) the second complement inhibitor is eculizumab or OMS721; (b) the anti-CD20 antibody is rituximab; (c) the anti-CD25 antibody is daclizumab; (d) the vinca alkaloid is vincristine; and/or (e) the statin is pravastatin.

23. The method or the agent for use of any preceding claim wherein the functional equivalent of the protein comprising amino acids 19 to 168 of SEQ ID NO:2 is a fusion protein comprising (a) a sequence as defined in any of claims 6 to 14, and (b) a second sequence and said fusion protein binds C5 to prevent the cleavage of complement C5 by convertase into complement C5a and complement C5b and binds LTB4.

24. The method or agent for use of claim 23 wherein said second sequence is a PAS sequence.

25. The method or agent for use of claim 23 or 24, wherein said fusion protein comprises multiple copies of one of ASPAAPAPASPAAPAPSAPA (SEQ ID NO: 15); AAPASPAPAAPSAPAPAAPS (SEQ ID NO: 16); APSSPSPSAPSSPSPASPSS (SEQ ID NO: 17), SAPSSPSPSAPSSPSPASPS (SEQ ID NO: 18), SSPSAPSPSSPASPSPSSPA (SEQ ID NO: 19), AASPAAPSAPPAAASPAAPSAPPA (SEQ ID NO: 20) and ASAAAPAAASAAASAPSAAA (SEQ ID NO: 21), preferably 20-30 or 30 copies of one of SEQ ID NOs 15-21.

26. The method or agent for use of any of claims 23 to 25, wherein said fusion protein comprises (a) a PAS sequence consisting of 30 copies of SEQ ID NO:15 and (b) (i) amino acids 19-168 of SEQ ID NO:2, wherein (a) is fused to the N terminus of (b).

27. The method or agent for use of any of claims 23 to 26, wherein said fusion protein comprises the sequence of SEQ ID NO:22.

28. The method or agent for use of any one of claims 1 to 27, wherein the protein or fusion protein binds C5 to prevent the cleavage of complement C5 by convertase into complement C5a and complement C5b and binds LTB4.

Description

BRIEF DESCRIPTION OF FIGURES

[0156] FIG. 1: Schematic diagram of classical and alternative pathways of complement activation. Anaphylatoxins enclosed in starbursts.

[0157] FIG. 2A: Primary sequence of nomacopan. Signal sequence underlined. Cysteine residues in bold type. Nucleotide and amino acid number indicated at right.

[0158] FIG. 2B: Examples of nomacopan variants.

[0159] FIG. 3: Table showing the clinical progression of two HSCT-TMA patients that were treated with nomacopan.

[0160] FIG. 4: Complement activity in HSCT-TMA patients after treatment with nomacopan.

[0161] FIG. 5: Level of free nomacopan in the serum of HSCT-TMA patients after treatment with nomacopan.

[0162] FIG. 6: PAS-nomacopan sequence.

EXAMPLE

[0163] Two patients with HSCT-TMA were treated with nomacopan, and the results are shown in FIG. 3. This was part of a named patient program in the UK.

[0164] The first patient (patient 1 in FIG. 3) was diagnosed with HSCT-TMA in early June 2018 having had a HSCT transplant for treatment of acute lymphoblastic leukemia on 19 Jan. 2018. At presentation, the patient had no signs of active infection or GVHD but had tremor and abdominal pain, skin lesions, hypertension, edema, weight gain, and blood abnormalities including thrombocytopenia, anemia, elevated LDH, red blood cell fragments. She also had proteinuria and erythrocyturia, very high soluble terminal complement complex (sC5b9) levels (692 ng/mL) and neurological impairment. The patient received nomacopan dosing described in Table 1 starting on the 8 Jun. 2018 and resolved her symptoms of HSCT-TMA within 63 days of initiating nomacopan (FIG. 3), She developed no infections or GVHD and was alive and well more than 1.5 years after the treatment for HSCT.

[0165] The second patient (patient 2) was diagnosed with HSCT-TMA on the 19 Apr. 2018 having had a HSCT transplant on the 9 Feb. 2018 for treatment of high risk acute myeloid leukaemia. At presentation the patient had lung GVHD, raised LDH, red blood cell fragments, thrombocytopenia, hemolytic anemia, proteinuria, elevated sC5b9 and was Coomb's negative. The patient received nomacopan dosing described in Table 1 starting on the 9 Jul. 2018 (more than 2.5 months after diagnosis of TMA) and resolved many of her symptoms of HSCT-TMA within 28 days of initiating nomacopan (FIG. 3), However her lung GVHD worsened and she died of complications caused by the lung GVHD shortly after coming off nomacopan.

[0166] In both of these patients and three other HSCT-TMA named patients (patients 3-5) terminal complement activity measured by CH50 ELISA (FIG. 4) and free nomacopan levels were assessed (FIG. 5). The data show that the doses of nomacopan used to treat the HSCT-TMA pediatric patients rapidly and completely inhibited complement activity.

TABLE-US-00005 TABLE 1 dosing regimen Patient Age; Ablating Initiation Ablating Initiation Maintenance ID Weight Dose 1 Dose 1 Dose 2 Dose 2 Dose Outcome Patient 5 years;   38 mg 10.4 mg  N/A N/A 20.7 mg TMA 1   23 kg and 19 every 12 every 12 resolved, mg 12 hours hours from survived to hours from Day Day 22-56 Day 200+ later .sup.a 2-21 Patient 2 years; 18.3 mg   5 mg 18.3 mg 6.7 mg N/A TMA 2   12 kg and 9.2 every 12 and 9.2 every resolved, mg 12 hours mg 12 12 hours died of lung hours from Day hours from GVHD later .sup.a 2-16 later at Day 18- Day 17.sup.a EOS Patient 5 years; 19.6 mg   8 mg N/A N/A N/A Incomplete 3 17.8 kg and 9.8 every 12 information mg 12 hours TMA hours from Day response, later 2-EOS died of fungal infection Patient 2 years; 18.2 mg 7.4 mg N/A N/A N/A Incomplete 4 16.5 kg and 9.1 every 12 information mg 12 hours TMA hours from Day response, later 2-EOS died of infection Patient 5 years; 18.5 mg 6.9 mg N/A N/A N/A Incomplete 5 18.5 kg and 9.25 every 12 information, mg 12 hours died hours from Day later 2-EOS EOS = end of study; GVHD = graft versus host disease; N/A = not applicable; TMA = thrombotic microangiopathy. .sup.a First 2 subjects (patient 1 and patient 2) received a higher ablating dose on a mg/kg basis than patients 3-5.

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