IL-18 Binding Protein (IL-18BP) In Respiratory Diseases

Abstract

The present invention provides means and methods for treating Interleukin 18 (IL-18)-associated respiratory diseases and disorders, particularly means and methods for treating virus-induced IL-18 associated respiratory diseases. In particular, the present invention discloses IL-18 inhibitors such as, for example, the IL-18 binding protein (IL-18BP) for use in the treatment of Interleukin 18 (IL-18)-associated respiratory diseases and disorders such as virus-induced ARDS.

Claims

1. A method of treating a respiratory disease in a subject, which disease is caused by virus-induced infection, the method comprising steps of administering to the subject an IL-18 inhibitor.

2. The method of claim 1, wherein the respiratory disease is Acute Respiratory Distress Syndrome (ARDS).

3. The method of claim 1, wherein the virus infection is caused by a virus selected from the group consisting of Rhinovirus, RSV, Influenza virus, Parainfluenza virus, Metapneumovirus, Coronavirus, Enterovirus, Adenovirus, Bocavirus, Polyomavirus, Herpes simplex virus, and Cytomegalovirus.

4. The method of claim 3, wherein the Coronavirus is of the genus α-CoV, β-CoV, γ-CoV or δ-CoV.

5. The method of claim 3, wherein the Coronavirus is selected from the group consisting of Human coronavirus OC43 (HCoV-OC43), Human coronavirus HKU1 (HCoV-HKU1), Human coronavirus 229E (HCoV-229E), Human coronavirus NL63 (HCoV-NL63, New Haven coronavirus), Middle East respiratory syndrome-related coronavirus (MERS-CoV or “novel coronavirus 2012”), Severe acute respiratory syndrome coronavirus (SARS-CoV or “SARS-classic”), and Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or “novel coronavirus 2019”).

6. The method of claim 3, wherein the Influenza virus is of type A, B, C or D, in particular of type A.

7. The method of claim 3, wherein the Coronavirus-induced disease is selected from the group consisting of Middle East Respiratory Syndrome (MERS), Severe Acute Respiratory Syndrome (SARS) and COVID-19.

8. The method of claim 3, wherein the Coronavirus is Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or “novel coronavirus 2019”) or a variant thereof and the Coronavirus-induced disease is COVID-19.

9. The method of claim 1, wherein treatment is achieved and/or supported by blocking the proinflammatory activity of IL-18.

10. The method of claim 1, wherein the IL-18 inhibitor is: (a) an IL-18 binding protein (IL-18BP); (b) a human IL-18BP (hIL-18BP); or (c) a recombinant human IL-18BP (rhIL-18BP), including any functional equivalent or functional part thereof which retains the capability of blocking the proinflammatory activity of IL-18.

11.-12. (canceled)

13. The method of claim 10, wherein said human IL-18BP is selected from isoform a, b, c and d of human IL-18BP, particularly isoform a as in SEQ ID NO: 2, isoform b as in SEQ ID NO: 3, isoform c as in SEQ ID NO: 4 or isoform d as in SEQ ID NO: 5, including any functional equivalent or functional part of isoforms a, b, c and/or d which retains the capability of blocking the proinflammatory activity of IL-18.

14. The method of claim 10, which is an IL-18BP as shown in SEQ ID NO: 2, including any functional equivalent or functional part thereof which retains the capability of blocking the proinflammatory activity of IL-18.

15. The method of claim 10 wherein (a) the functional equivalent has a sequence identity of 80%, 85%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% to the sequence depicted in SEQ ID NO: 2 and retains the capability of blocking the proinflammatory activity of IL-18; or (b) the functional equivalent or functional part thereof includes a mutein of IL-18BP, a fragment, a peptide, a functional derivative, a functional fragment, a fraction, a circularly permuted derivative, a fused protein comprising IL-18BP, an isoform or a salt thereof which retains the capability of blocking the proinflammatory activity of IL-18.

16. (canceled)

17. The method of claim 10, wherein the IL-18 inhibitor comprises in addition to the IL-18 binding protein (IL-18BP), N-terminal and/or C-terminal deletion variants of IL-18BP in an amount of up to 0.01%, 0.05%, 0.1%, 0.25%, 0.5%, 1%, 2.5%, 5%, 7.5%, 10%, 15%, 20%, 30%, or 40%.

18. The method claim 17, wherein said deletion variants comprise deletions of between 1 and 5 amino acid residues at the C-terminal end of the IL-18BP and/or between 1 and 30 amino acid residues at the N-terminal end of the IL-18BP.

19. (canceled)

20. The method of claim 1, wherein the body fluids and/or body tissues of the subject to be treated have been quantified to have abnormal levels of free IL-18, which exceed the level of free IL-18 in body fluids and/or body tissues of a healthy control subject by 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, or more than 100%, using an assay capable of detecting free IL-18 in body fluids and/or body tissues, said assay comprising IL-18BP or an antibody or a functional part thereof, which antibody or active part thereof binds to IL-18 at the binding site of IL-18BP or in the vicinity of the binding site of IL-18BP, but does not bind IL-18/IL-18BP complexes.

21. The method of claim 20, wherein (a) the level of free IL-18 is above the quantification limit of >12 pg/mL, and/or above the detection limit of >4 pg/mL; or (b) the level of free IL-18 is two to three times above the level of a healthy control subject.

22. (canceled)

23. The method of claim 1, wherein the subject has a level of ferritin above 400 ng/mL, preferably above 1000 ng/mL.

24. The method of claim 20, wherein the assay for quantifying the level of free IL-18 in the body fluids and/or body tissues comprises the following steps: a) bringing a sample of body fluid and/or body tissue suspected to contain free IL-18 into contact with the IL-18 inhibitor as defined in any one of claims 9 to 19 as the capturing molecule for free IL-18; b) allowing the IL-18 inhibitor to bind free IL-18; c) detecting the binding of the IL-18 inhibitor and determining the amount of free IL-18 in the sample.

25. The method of claim 20, wherein the body fluids and/or body tissues are selected from the group consisting of broncho-alveolar lavage fluid (BALF) circulation fluids, secretion fluids, biopsy, and homogenized tissue, particularly serum, urine, tear, saliva, bile, sweat, exhalation or expiration, sputum, bronchoalveolar fluid, sebum, cellular, gland, mucosa or tissue secretion.

26. (canceled)

27. The method of claim 1, wherein said IL-18 inhibitor or composition is administered to a subject in need thereof, wherein the administration is (a) a single dose/day, in multiple doses/day, in multiple doses/week or in multiple doses/month; (b) one dose per week, in two doses per week, three doses per week, four doses per week, five doses per week, six doses per week, or seven doses per week; (c) every 24 hours to 48 hours; or (d) a single dose every other day, for example, over three weeks.

28.-30. (canceled)

31. The method of claim 1, wherein a single dose comprises between 0.5 mg of IL-18 inhibitor/kg body weight and 10 mg IL-18 inhibitor/kg body weight.

32. The method of claim 1, wherein a single dose of between 0.5 mg IL-18 inhibitor/kg body weight and 5 mg IL-18 inhibitor/kg body weight is administered every 24 or 48 h.

33. The method of claim 10, wherein the IL-18 inhibitor is a recombinant human IL-18BP (rhIL-18 BP), including any functional equivalent or functional part thereof, which retains the capability of blocking the proinflammatory activity of free IL-18, wherein the recombinant human IL-18BP (rhIL-18 BP) is administered in a single dose every other day of 2 mg/kg body weight.

34. The method of claim 1, wherein the subject, is a human with confirmed SARS-CoV-2 infection undergoing systemic inflammatory reaction and in need of respiratory assistance.

35. The IL-18 inhibitor claim 1, wherein the subject suffers from SARS-Cov-2 showing uncontrolled systemic inflammatory reactions and/or high levels of total IL-18 and/or total IL-18BP and/or detectable levels of free IL-18.

36. The method of claim 1, wherein the IL-18 inhibitor and/or the composition are used in co-medication with an anti-viral agent an anti-inflammatory agent, an immunosuppressant, a monoclonal antibody a cocktail of monoclonal antibodies, a vasopressor, an anticoagulant and/or, a vasodilator, and/or a mucolytic.

37. The method of claim 36, wherein the anti-viral agent is selected from the group consisting of Remdesivir, Chloroquine, Hydroxychloroquine, Lopinavir, Ritonavir, interferon-β, Interferon-α, and Ivermectin.

38. The method of claim 36, wherein the anti-inflammatory agent and the immunosuppressant is selected from the group consisting of Corticosteroids, intravenous immunoglobulin, Tocilizumab (anti-IL-6 receptor), sarilumab (anti-IL-6 receptor), canakinumab (anti-IL-1 beta) anakinra (recombinant IL-1ra), Emapalumab (anti-IFNγ), and JAK inhibitors.

39. The method of claim 36, wherein the monoclonal antibody is selected from REGN-COV2, LY-COV55, and CT-P59.

40. The method of claim 1, wherein the subject to be treated is a mammal or a human.

41.-47. (canceled)

Description

BRIEF DESCRIPTION OF THE FIGURE

[0248] FIG. 1: Correlation plots. Scatterplots of all the pairs of variables, accompanied by a loess curve indicating the trend. The correlations between the variables are indicated in the top-right triangle (font size is proportional to the absolute value of the correlation)

EXAMPLES

Example 1

Free IL-18, Total IL-18 and IL-18BP Levels in SARS-Cov-2 Patients

[0249] 1.1 Study Population

[0250] 37 serum samples obtained from hospitalized patients with confirmed SARS-CoV-2 infection by reverse-transcriptase-polymerase chain reaction (RT-PCR) undergoing systemic inflammatory reaction and in need of respiratory assistance were analyzed for C-reactive protein (CRP), ferritin, glutamic oxaloacetic transaminase (GOT, also called AST), total IL-18, free IL-18 and IL-18BP levels.

[0251] In the clinical course of SARS-CoV-2 infection some patients deteriorate and progress to a status of uncontrolled inflammatory reaction that has been called “cytokine release syndrome”. It has been acknowledged that the body's detrimental inflammatory response is the main factor that leads to multiple organ failure and poor prognosis. In the clinical setting the increase of inflammatory markers such as CRP and ferritin are the main tools to assess the increasing inflammation.

[0252] 1.2. Assay Design

[0253] 1.2.1 Total IL-18:

[0254] Total IL-18 in the serum samples was determined with the Human IL-18 ELISA kit (Medical & Biological Laboratories Co., LTD. Code No. 7620). This kit is based on the quantitative sandwich enzyme immunoassay technique. The assay referenced above uses two monoclonal antibodies against two different epitopes of human IL-18. In wells coated with a first anti-human IL-18 monoclonal antibody, samples or reference standards are incubated. After a washing step, a second anti-human IL-18 monoclonal antibody which is conjugated to horseradish peroxidase is added into the microwell and incubated. After another washing step, the peroxidase substrate is mixed with the chromogen and allowed to incubate for an additional period of time. An acid solution is then added to each well to terminate the enzyme reaction and to stabilize the developed colour. The optical density (O.D.) of each well is measured at 450 nm using a microplate reader. The concentration of human IL-18 is calibrated from a dose response curve based on reference standards.

[0255] 1.2.2 Free IL-18:

[0256] Free IL-18 in the serum samples was determined with the assay as described in WO 2015/032932 and WO 2016/139297. For this analysis the limit of quantification was 12 pg/mL and the limit of detection was 4 pg/mL.

[0257] Microplate wells are coated with an appropriate volume phosphate buffer saline solution containing recombinant human IL-18BP. Plates are incubated for a period of time at 4° C. and then stabilized with a blocking buffer containing bovine serum albumin or other appropriate blocking agents. Once the reaction is finished, microplates are sealed and stored at 4° C. until used for detection of free IL-18. Microplates can also be dried in a stabilizing solution allowing storage at room temperature and then be reconstituted by hydration when needed for assay.

[0258] For a final reaction volume of 100 μl, first 80 μl of biotin/antibody conjugate are dispensed. Samples or biological fluids containing free IL-18 are tested with the IL-18BP coated microplates. After that, 20 μl sample volume containing biological fluid or standard is dispensed per microplate well. The free IL-18 standard concentrations range between 4.2 pg/ml to 3000 pg/ml. Standard concentrations were prepared from commercially available recombinant human IL-18. The plates are sealed and then incubated under gentle shaking for free IL-18 capture. A suitable period of time is allowed for the reaction ranging from minutes to hours at room temperature, 37° C. or other temperatures that do not affect the stability of the samples and reagents. The microplate wells are washed extensively with the appropriate buffer and then, 100 μl buffer developing mixture is added to each well. The developing mixture contains a streptavidin-conjugated enzyme such as peroxidase or alkaline phosphatase. The microplate wells are sealed and the reaction is allowed for a suitable period of time ranging from minutes to hours at room temperature, 37° C. or other temperatures that do not affect the stability of the samples and reagents. The resulting reactions are then monitored with a microplate reader at an appropriate nanometer wavelength for absorbance or fluorescence of the produced reagent.

[0259] 1.2.3 Ferritin:

[0260] Ferritin in the serum samples was determined with the ECLIA Test Kit from Roche Diagnostics, analyzed on Cobas 6000 e601 from Roche Diagnostics

[0261] The test method is based on the sandwich-principle. As a first step of the reaction, the analyte (ferritin) forms a sandwich-complex with on the one hand a monoclonal ferritin-specific antibody, labelled with biotin and on the other hand a monoclonal ferritin-specific antibody, labelled with a ruthenium-complex. After addition of streptavidin-coated magnetic microparticles to the solution, the sandwich-complex binds via biotin-streptavidin interaction to the solid phase. By magnetic separation the microparticles are fixed to the surface of an electrode. Application of voltage induces chemiluminescent emission which is measured by a photomultiplier. The concentration of ferritin in the samples is then extrapolated from a standard curve.

[0262] 1.2.4 CRP:

[0263] CRP in the serum samples was determined with an immunoturbidimetric test from Roche Diagnostics, analyzed on Cobas 6000 c501 from Roche Diagnostics

[0264] The human CRP test kit is based on an immunoturbidimetric method. CRP in the samples agglutinates with latex particles coated with monoclonal anti-CRP antibodies. The aggregates are determined turbidimetrically.

[0265] 1.2.5 AST/GOT:

[0266] AST/GOT (glutamic oxaloacetic transaminase, also named Aspartate transaminase or AST), in the serum samples was determined with an enzymatic test from Roche Diagnostics, analyzed on Cobas 6000 c501 from Roche Diagnostics.

[0267] AST catalyzes the reaction between L-alanine and 2-oxoglutarate and the produced pyruvate is reduced by Lactate Dehydrogenase in presence of NADH to L-lactate and NAD+.

[0268] 1.2.6 Biostatistical Analysis:

[0269] All statistical analyses were performed using the R statistical package (version 4.0.3). The correlation coefficient indicates the (linear) correlations between all pairs of variables. Correlation coefficients are between −1 and 1; a correlation coefficient around 0 indicates no linear relationship between two variables (a cloud of points with no obvious structure linking the two variables); the closer the value approaches 1, the stronger the positive linear association. Similarly, the closer the value approaches −1, the stronger the negative linear association (when one value increases, the other one tends to decrease).

[0270] 1.3 Results

[0271] The results of the above described assays are summarized in Table 1 and FIG. 1.

[0272] 1.4 Discussion

[0273] All values for total IL-18 were above values of healthy controls (<260 pg/mL) ranging from 341 to 1734 pg/mL with an average of 585.5 pg/mL and a median of 520 ng/mL. In addition, three patients showed levels of free IL-18 above the quantification limit and eighteen patients were reported with values of free IL-18 above the limit of detection (between 4 pg/mL and 12 pg/mL). Healthy patients had undetectable free IL-18 amounts. All values for IL-18BP were above the values of healthy controls (2000 and 3000 pg/mL) ranging from 34506 to 180288 pg/mL with an average of 80254.6 pg/mL and a median of 77532 pg/mL.

[0274] Uncontrolled systemic inflammatory reactions were shown by high levels of ferritin ranging from 106 to 3825 ng/mL with an average of 1306 ng/mL and a median of 1178 ng/mL (values of healthy controls 30-400 ng/mL), high levels of CRP ranging from 8 to 341 μg/mL with an average of 127 ng/mL and a median of 106 ng/mL (values of healthy controls <5 μg/mL) and high levels of GOT ranging from 25 to 266 U/L with an average of 83 U/L and a median of 71 U/L (values of healthy controls 5-40 U/L). These uncontrolled systemic inflammatory reactions result from the activation of macrophages and lymphocytes and are driven, at least partially, by high levels of IL-18 and the appearance of free IL-18. Macrophage activation syndrome is a life-threatening complication of the systemic inflammatory disorders with unremitting fever, hyperferritinemia, high CRP, pancytopenia, coagulopathy and liver damage as shown by the high levels of serum enzymes released from damaged hepatocytes (AST/GOT, normal ranges age and gender dependent).

[0275] Since the serum concentrations of these analytes were greater than the concentrations observed in healthy individuals (normal levels), cut off values for each parameter were defined so that the set of values was divided in two groups (below and above threshold) of similar sizes. The below and above threshold groups correspond to medium and high levels, respectively.

[0276] Among the 22 patients presenting high (hi) levels of Ferritin (>1000 μg/L; FERRhi): [0277] 20 (91%) also presented high levels of CRP (>90 mg/L; CRPhi) [0278] 16 (73%) also presented high levels of GOT (>60 U/L; GOThi) [0279] 16 (73%) also presented high levels of total IL-18 (>500 pg/mL; IL-18hi) [0280] 19 (86%) also presented high levels of IL-18BP (>72000 pg/mL; IL-18BPhi)

[0281] Among the 14 patients presenting medium (med) levels of Ferritin (<1000 μg/L; FERRmed): [0282] Only 3 (21%) presented high levels of CRP (CRPhi) [0283] 6 (43%) presented high levels of GOT (GOThi) [0284] Only 3 (21%) presented high levels of total IL-18 (IL-18hi) [0285] Only 2 (14%) presented high levels of IL-18BP (IL-18BPhi)

[0286] In 27 out of 37 patients, IL-18 and IL-18BP levels co-segregated: [0287] Only 4 patients showed high IL-18 and medium IL-18BP [0288] Only 6 patients showed high IL-18BP and medium IL-18

[0289] The systemic inflammation that these Covid-19 patients experienced was reflected by above the normal levels of serum Ferritin, CRP and GOT. When these patients were distributed into high or medium levels subgroups, FERRhi patients co-segregate with CRPhi patients, and to a lesser extent to GOThI patients.

[0290] This inflammation was accompanied by the induction of IL-18 pathway, as all inflamed patients presented above the normal levels of total IL-18 and IL-18BP. Moreover, the patients exhibiting the highest inflammatory condition (FERRhi) were the ones having high total IL-18 and IL-18BP levels. The total IL-18 co-segregates with the inflammatory status as FERRhi IL-18hi patients represented a major fraction of FERRhi patients (16 out of 22), and also a major fraction of all patients presenting high IL-18 levels (16 out of 19). The same was found for IL-18BP, with FERRhi IL-18BPhi representing 19 out of 22 FERRhi and 19 out of 21 IL-18BPhi. Therefore, the inflammation observed in these severe Covid-19 patients is associated with above the normal levels of both total IL-18 and IL-18BP, and its extent corresponds to the highest levels in these parameters.

[0291] The IL-18 induction leads to an increased expression in both IL-18 and IL-18BP, and the data revealed that these parameters largely co-segregate: only 4 out of 37 patients exhibited IL-18hi and IL-18BPmed and 6 patients had IL-18med and IL-18BPhi. Nevertheless, free IL-18 is detected in the majority (24 out of 37) of serum samples. This suggests that the observed increased amounts of IL-18BP relative to the ones of IL-18 are not sufficient and that a large molar excess of IL-18BP over IL-18 is needed to displace the complex equilibrium and keep IL-18 in a complexed inactive status, thus eliminating free IL-18 species.

[0292] An additional biostatistical analysis of the results presented in Table 1 was performed in order to determine whether there exists a correlation between these measured parameters, in order to define sub-groups of patients sharing similar characteristics.

[0293] The correlation plots indicated that some of the highest correlations are found between IL-18BP and CRP (0.63), as well as between FERR and CRP (0.59) and between IL-18BP and FERR (0.39). The scatterplots showing these pairs of variables indicate indeed a clear relationship between these variables (see FIG. 1). Other high correlations are observed between IL-18BP and free IL-18 (IL-18F) (0.64), between IL-18BP and IL-18 (0.44) and between FERR and IL-18 (0.42). However, their corresponding correlation plots tend to indicate that these higher correlation values are mostly driven by a few outlier points. The Pearson correlation is known to be sensitive to such outliers.

[0294] Detection of above the normal serum levels in the inflammatory biomarkers FERR, CRP and GOT confirmed that the severe Covid-19 patients tested in this study experienced a systemic inflammation. Moreover, patients presenting high FERR levels (FERRhi) also had high CRP levels, while they co-segregated to a lesser extent with patients presenting high GOT levels. This was confirmed by the biostatistical analysis, since one of the highest correlations was found between FERR and CRP (0.59), whereas no good correlation was observed between FERR and GOT (0.38, but driven by only one outlier point), nor between CRP and GOT (0.19). Thus, within the present invention, an increased FERR level can be used as additional marker either alone or together with CRP as a marker.

[0295] This study revealed that severe Covid-19 patients exhibit not only high serum concentrations in IL-18, but also high levels of IL-18BP. The association between hyperinflammation and the induction of the IL-18 pathway is reflected by the fact that the most inflamed patients (FERRhi) presented high levels of IL-18 and IL-18BP. This is further supported by the statistical analysis which revealed high correlations between CRP and IL-18BP (0.63); FERR and IL-18BP (0.39), as well as between FERR and IL-18 (0.42).

[0296] Therefore, the hyperinflammation is associated with the induction of the IL-18 pathway, with both IL-18 and IL-18BP levels being increased. Still, the patients' population is heterologous and for a small fraction of them, IL-18 and IL-18BP do not co-segregate. This is reflected by a correlation between both parameter (0.44) that is only driven by a few outlier points. Moreover, even though the production of both molecules is increased, the amounts of IL-18BP is not sufficient to bind and neutralize IL-18, as seen by the appearance of free IL-18 species. It could be that this is due to a dynamic equilibrium between bound and free IL-18 and a large molar excess of IL-18BP over IL-18 is needed to stabilize the complex, or to the generation of non-functional IL-18BP species in some patients. In both cases, free IL-18 species can be detected and the pathogenically appearance of free IL-18 in the serum of these patients reveals that the inflammation they are experiencing is largely uncontrolled.

[0297] In conclusion, high levels of total IL-18 and IL-18BP were found in SARS-Cov-2 patients undergoing systemic inflammatory reaction and in need of respiratory assistance. In addition, two patients exhibited levels of free IL-18 above the quantification limit (>12 pg/mL) and eighteen patients presented detectable levels (>4 pg/mL), while still below the quantification limit. The results indicate a strong implication of the IL-18 pathway in patients with severe SARS-Cov-2 infection and support the use of IL-18 inhibitor such as rhlL-18BP (Tadekinig alfa) to treat such patients. Tadekinig also has proven effect in patients with diseases related to the IL-18 pathway, the same mechanism that is of high relevance for future treatments of patients with severe SARS-Cov-2 infection because the elevated IL-18 levels in such patients are linked with a cytokine release syndrome with the high probability of a fatal outcome.

Example 2

rhIL-18BP Compassionate Use Treatment for Hospitalized Patient with Severe S S-CoV-2 Infection

[0298] For a group of selected patients, IL-18 blockade with rhlL-18BP (Tadekinig alfa) is proposed. SARS-CoV-2 patients at various stages of the disease may benefit from the treatment. In particular, however not limited thereto, patients undergoing severe ARDS with presence or not of organ failures and a biological reaction characterized by very high levels of ferritin, cytopenias and coagulopathies, mimicking MAS may benefit more of this targeted treatment.

[0299] 2.1. Objectives

[0300] Primary Objective:

[0301] To show the clinical and biological efficacy of IL-18 blockade with Tadekinig alfa in SARS-CoV-2 patients with underlying MAS like reaction.

[0302] Secondary Objective:

[0303] To show the safe use of IL-18 blockade with Tadekinig alfa in SARS-CoV-2 patients with severe disease.

[0304] 2.2. Stud Design

[0305] Compassionate use cases studies including around 5 patients.

[0306] 2.3. Study Population

[0307] 2.3.1 Inclusion Criteria [0308] Males or females≥18 years of age. [0309] Hospitalized patients with confirmed SARS-CoV-2 diagnosis by PCR. [0310] Patients with acute respiratory failure (including patients in need of mechanical ventilation). [0311] Patients with worsening clinical or radiologic/CT condition despite standard of care or antiviral agents, or [0312] Patients with new onset organ failures as shown by >3 points on the SOFA score, or [0313] Patient with increased need of vasopressors, and/or [0314] Patients with increasing levels of systemic biomarkers: Ferritin, thrombocytopenia, liver enzymes, low fibrinogen, IL-6, d-dimers.

[0315] 2.3.2 Exclusion Criteria [0316] Physician decision that enrolment is not in the patient's best interest.

[0317] 2.4 Study Procedures

[0318] 2.4.1 Duration

[0319] One to eight weeks treatment will be followed by a 4-week follow-up period for safety assessments. Data management, statistical and study report will take approximately 4 more months.

[0320] 2.4.2 Study Drug

[0321] IL-18BP, in particular rhlL-18BP (Tadekinig alfa) isoform a as shown in SEQ ID NO: 2.

[0322] 2.4.3 Composition

[0323] The drug product formulation (recombinant human interleukin 18 Binding protein (rhlL-18BP as shown in SEQ ID NO: 2) will have a strength of 80 mg, and is prepared in a sterilized solution for injection containing sodium chloride, 7 mg per vial, sodium dihydrSEQogen phosphate monohydrate approx. 1.0 mg per vial, disodium phosphate dehydrate approx. 2.4 mg per vial, sodium hydroxide and O-phosphoric acid 85% to adjust to pH 7.0, water for injection up to 1 ml.

[0324] Glass vials containing 1 ml of the injection volume and 80 mg of the recombinant molecule (rhIL-18BP) will be the administration unit.

[0325] 2.4.4 Dose/Route Regime

[0326] Open label administration of Tadekinig alfa (rhlL-18BP), at 2 mg/Kg body weight (BW) every other day for three weeks added on to the standard of care. [0327] Permitted co-medications and standard medical care: [0328] O2 supplementation, non-invasive or invasive ventilation, antibiotics, vasopressor support, antiviral agents, anti-inflammatory and immunosupressant.

[0329] The product comes as a solution to be administered by the s.c. route. Glass vials contain 1 ml with a 15% overfill with a dose of 80 mg of the active product. Patients in the 160 mg and 320 mg cohorts will receive separate s.c. injections of 1 ml each: 2 injections of 1 mL for the 160 mg dose and 4 injections of 1 mL for the 320 mg dose. A separate syringe must be used for each injection.

[0330] The site of the s.c. injection should be alternated e.g. the outside of the thighs and the various quadrants of the anterior abdominal wall. The separate injections that constitute a single dosage of study drug should be administered within the same body region but not at the exact same injection site.

[0331] 2.4.5 Clinical and Biological Monitoring During Follow-Up [0332] Daily patient assessment by trained nurses included: [0333] Presence/absence of fever, respiratory rate, systolic blood pressure, level of blood oxygenation, lung and cardiac auscultation. [0334] Daily laboratory controls include: [0335] White cell counts, platelet counts, CRP, ferritin), serum creatinine, ALT, AST, LDH, Creatinine kinase. [0336] Required co-medications.

[0337] 2.5. Outcome Measures.

[0338] 2.5.1 Clinical Assessment

[0339] The seven-category ordinal scale will be utilized for clinical assessment, and two-point improvement or live discharge from hospital, will be considered a positive response to treatment.

[0340] The seven-category ordinal scale consisted of the following categories: [0341] 1, not hospitalized with resumption of normal activities; [0342] 2, not hospitalized, but unable to resume normal activities; [0343] 3, hospitalized, not requiring supplemental oxygen; [0344] 4, hospitalized, requiring supplemental oxygen; [0345] 5, hospitalized, requiring nasal high-flow oxygen therapy, noninvasive mechanical ventilation, [0346] Or both; [0347] 6, hospitalized, requiring ECMO, invasive mechanical ventilation, or both; and [0348] 7, death.

[0349] 2.5.2 Biological Assessment [0350] Ferritin [0351] CRP [0352] Thrombocytes [0353] Liver enzymes (ALT, AST) [0354] LDH [0355] Creatinine 2.6 Safety Evaluation.

[0356] Safety outcomes will include adverse events that occur during treatment, serious adverse events, and premature discontinuation of treatment.

TABLE-US-00002 TABLE 1 Table 1: Analysis of serum samples obtained from hospitalized patients with confirmed SARS-Cov-2 infection CRP Ferritin GOT (AST) Total IL-18 IL-18BP Free IL-18 Free IL18 Sample No age μg/mL ng/mL U/L pg/mL pg/mL pg/mL Raw data 0880237562 31 57.3 1637 25 629 58292 BLQ 5.06 0880237563 56 222.5 937.8 40 467 71575 BLQ 8.82 0880237564 55 134.4 1116 146 553 93121 BLQ 9.12 0880237565 58 84.7 780.4 105 496 85314 BLQ 6.46 0880237566 57 32.9 555.8 56 358 66712 BLD 2.42 0880237567 53 119.3 480.9 146 704 61585 NVR 13.67 0880237568 54 54.8 105.6 44 392 58773 BLD 4.75 0880237569 55 90.5 459 135 627 54668 BLQ 7.40 0880237570 59 341.7 1833 87 520 107536 BLQ 6.93 0880237571 60 307.1 1998.5 67 341 87701 NVR 12.41 0880237572 60 8.2 841.6 44 434 34506 BLD 3.97 0880237573 58 NVR NVR NVR 412 51796 NVR 0.41 0880237574 51 207.9 1372 42 882 100828 BLQ 9.27 0880237575 59 165.6 2244.5 72 941 78975 12 11.93 0880237576 60 88.5 1463 64 520 74480 BLQ 6.00 0880237577 55 35.7 1035 142 412 64502 BLD 3.20 0880237578 51 100.8 1134 62 521 87058 BLQ 6.78 0880237579 45 55.8 1358 135 561 72331 BLQ 5.37 0880237580 48 14.3 940.2 70 425 5687.2 BLD 3.35 0880237581 35 269.8 1890 106 861 114562 BLQ 5.68 0880237582 49 12.5 812 43 378 70600 BLD 3.04 0880237583 50 14.8 948.1 92 349 48335 BLD 2.88 0880237584 55 258.6 1695.5 104 451 76681 BLD 2.89 0880237585 51 20.9 834.6 59 384 63778 BLD 1.96 0880237586 64 245.4 3825 266 639 104232 BLQ 6.78 0880237587 67 13.2 1246 72 644 84531 BLD 1.49 0880237588 60 208.4 2642 73 1734 99963 BLQ 6.78 0880237589 69 43.5 862.6 44 847 53424 BLQ 6.93 0880237597 45 20.4 901 36 457 89932 BLD 1.49 0880237598 55 114.6 1680 100 455 68040 BLQ 6.62 0880237599 58 248.3 1575 56 666 85146 BLQ 6.15 0880237600 55 197.9 1678 53 615 78383 BLD 2.26 0880237601 53 143.6 1406 57 762 112127 BLQ 4.52 0880237602 57 72.3 769.5 123 455 66345 BLD 2.20 0880237603 60 254.8 1080 77 974 180288 15 14.93 0880237604 74 111.5 1662 54 445 96347 14 13.69 0880237605 76 186 1222 108 352 88120 BLQ 11.25 NVR: non valid result BLD: Below limit of detection, <4 pg/mL BLQ: Below limit of quantification, between 4 pg/mL and 12 pg/mL.