111111
`
`1111111111111111111111111111111111111111111111111111111111111111111111111111
`US 20050191298Al
`
`(19) United States
`(12) Patent Application Publication
`Bell et al.
`
`(10) Pub. No.: US 2005/0191298 A1
`Sep. 1, 2005
`( 43) Pub. Date:
`
`(54) METHOD OF TREATING HEMOLYTIC
`DISEASE
`
`Related U.S. Application Data
`
`(63)
`
`Continuation-in-part of application No. 10/771,552,
`filed on Feb. 3, 2004.
`
`(76)
`
`Inventors: Leonard Bell, Woodbridge, CT (US);
`Russell P. Rother, Prospect, CT (US)
`
`Publication Classification
`
`Correspondence Address:
`CDFS- 1087
`445 BROAD HOLLOW RD
`SUITE 225
`MELVILLE, NY 11747 (US)
`
`(21)
`
`Appl. No.:
`
`11/050,543
`
`(22)
`
`Filed:
`
`Feb.3,2005
`
`(51)
`Int. Cl? ........................ A61K 48/00; A61K 39/395
`(52) U.S. Cl. .............................. 424/144.1; 514/7; 514/44
`
`(57)
`
`ABSTRACT
`
`Paroxysmal nocturnal hemoglobinuria or other hemolytic
`diseases are treated using a compound which binds to or
`otherwise blocks the generation and/or the activity of one or
`more complement components, such as, for example, a
`complement-inhibiting antibody.
`
`1
`
`AMG1005
`
`

`

`(")
`
`~ .....
`
`""C
`~ .....
`~ = .....
`~ 't:l -....
`.... 0 =
`~
`0' -....
`.... 0 =
`
`(")
`
`~ .....
`
`Figure 1A.
`Biochemical Parameters of Hemolysis During Eculizumab Treatment
`
`Biochemical Marker
`
`Normal range
`
`LDH (IU/L)
`
`150-480
`
`Pre-study0
`3110.7 +/- 598.4
`
`Time of Analysis
`12 weeks
`594.0 +/- 31.7
`
`-64weeks
`622.4 +/-41.1
`
`p-value3
`
`0.002
`
`AST (IU/L)
`
`10-40
`
`76.2 +/- 16.0
`
`26.2 +/- 2.3
`
`30.1 +/- 3.2
`
`Haptoglobin (g/L)
`
`0.5-2
`
`<0.06
`
`<0.06
`
`0.14 +/- 0.07c
`
`Hemoglobin (g/dl)
`
`11.5- 18
`
`10.0 +/- 0.4
`
`10.3 +/- 0.4
`
`10.4 +/- 0.4
`
`Bilirubin
`
`3-15
`
`25.9 +/- 4.3
`
`28.2 +/- 4.4
`
`28.7 +/- 4.0
`
`Reticulocytes (x1o-
`3/mm3)
`
`20-80
`
`161.4 +/- 25.9
`
`191.2 +/- 23.6
`
`189.6 +/- 21.8
`
`0.02
`
`N.S.0
`
`N.S.
`
`N.S.
`
`N.S.
`
`~rom compansons of mean change from pre-study to 64 weeks
`bvalues represent means during 52 week period prior to treatment except for AST which represents the baseline mean
`c10 of 11 patients were below the detectable limit of haptoglobin {<0.06 g/L); 1 patient had a value of 0.69 g/L.
`dnot significant
`
`2
`
`

`

`Patent Application Publication Sep. 1, 2005 Sheet 2 of 11
`
`US 2005/0191298 A1
`
`Figure 1b
`
`'
`
`·· ..
`
`~.'
`
`.. ~ .
`
`. : ...
`
`... -
`
`.......
`
`·~ . ·., :
`
`... -~
`
`Figure 1 b: · LDH values during eculiiumab
`tllera.py . ·
`·. ·. ·
`. .
`:, .. · · · .
`-Intravascular henlolysla IS well contro'lled .bY ecullzumab.~s .
`·,
`lildleated' by, the martiea anit ~ustalnild reduction lnLDH (niean
`. .
`. u51i)e.~erSdeereased:from:311~·+t:sg~iUii.. over the 1~'months·•
`• prlor:tO treatment to 634 +t•. 34 U/L'durlng treatment (p=0.0021.:. ·
`- PatJimt'o1o.o1o.anit 011:.0o.1tlad transient breaktiiioughs.eai'ly In
`th~ tn!irtinent phase whl~ti .~ere eompletely ieso1~iKI ~y·: · · . ·
`. .-. '.' . > ... ~-' .
`adjustlngthe'd.C?slng liitei:yl!!· ·. ·. •.· ·· :·, .
`-Patient 010..002 dllicoritlilued ecullzumab near week 103 and LDH
`:.
`' . ··. .
`. ·
`. : ·
`· •.
`levels ~quickly Increased.~. ·
`· -~
`·.
`. - These sharp Increases In LDH llivels: demonstrate the causal
`relatloiuihlp'tietWeen complement activity and tieinolysls. '
`.
`.. ,, :
`'.
`. '
`.
`.
`.
`.
`' .
`.:::
`'
`. .
`~
`'
`
`~-" ...
`
`·.·.:,
`
`..
`
`3
`
`

`

`Patent Application Publication Sep. 1, 2005 Sheet 3 of 11
`
`US 2005/0191298 A1
`
`t~·--.·; .... .
`·: ., .. .
`: :~)·~_(~ .. ·-\·
`.. ... .
`::-•:....· .
`~: .;.:... · ... ';;;
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`Figure 2
`
`4
`
`

`

`Patent Application Publication Sep. 1, 2005 Sheet 4 of 11
`
`US 2005/0191298 A1
`
`Figure 3.
`Effect of Eculizumab on Paroxysm Rate (n=8)
`
`s: - 3.0
`5 2.5
`:= .,
`
`c
`~ 2.0
`cu
`
`a.. e !/) 1.5
`>-
`>< e
`:. 1.0
`.5
`
`!/)
`~ 0.5
`0
`
`Screening
`
`12weeks
`
`64weeks
`
`Bars represent the paroxysm rates (number of paroxysms per patient per month)
`during the screening period (pre-eculizumab treatment), and during the first 12
`weeks and the entire 64 weeks of eculizumab treatment. Three patients were
`not included in the analysis as either pretreatment urine scores were
`inadvertently not collected (2 patients) or an iron chelating agent ·that resulted in
`artificially colored urine was administered during the extension study (1 patient).
`
`5
`
`

`

`Patent Application Publication Sep. 1, 2005 Sheet 5 of 11
`
`US 2005/0191298 A1
`
`Figure 4.
`Analysis of Complement Breakthrough
`
`hemoglobinuria
`dysphagia
`
`Early Morning
`Urine
`
`Visit
`Day
`
`4
`0*
`10
`Urine
`LDH 2624
`AST
`119
`28
`PK
`PD
`72
`
`1-8
`2-3
`
`9
`3
`784
`38
`51
`1
`
`*Dose of eculizumab
`
`10
`3
`
`11
`3
`
`l-2
`3
`
`5
`0*
`13
`10
`9
`1687 2917
`87
`31
`56
`
`23
`56
`
`12
`3
`697
`31
`35
`2
`
`9
`0*
`2
`495
`
`51
`2
`
`6
`
`

`

`Fig 5. Patient 010-010 Urine Grade vs. Time
`Eculizumab - dosing. interval
`14 Days
`14 Days· 13 Days 13 Days · 12 Days
`
`(')
`
`~ .....
`
`""C
`~ .....
`~ = .....
`~ 't:l -....
`.... 0 =
`~ -a -....
`.... 0 =
`
`~ .....
`
`(')
`
`·~
`
`I
`
`-
`
`•
`
`' -~ ·2:
`I 1
`
`I I,
`
`•
`
`I
`
`-5 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
`Time (days)
`
`7
`
`

`

`Patent Application Publication Sep. 1, 2005 Sheet 7 of 11
`
`US 2005/0191298 A1
`
`Figure 6.
`Units Transfused Pre- and Post-Eculizumab in (a) Cytopenic
`Patients and (b) Non-Cytopenic Patients
`
`Patient ·· . a) ·
`.. ·
`010~01 .
`
`-
`
`Commencemem Of
`~~(Epo)
`
`. . li10~06 . .
`
`•
`l
`
`.. ·. s .,
`~11~01. ;'2. l
`. :l.
`... .
`o11~oi ·: :
`
`.. ·:.·'
`
`8
`
`

`

`(')
`
`~ .....
`
`""C
`~ .....
`~ = .....
`~ 't:l -....
`.... 0 =
`~
`0' -....
`.... 0 =
`
`(')
`
`~ .....
`
`Figure 7 Management of thrombocytopenic patient with erythropoietin
`
`Patient 010-001 (hypoplastic; platelets 80 to 100 x 1 09JI}
`
`Transfusions reduced with eculizumab and transfusion independence with combined
`eculizumab and erythropoietin (NeoRecormon 18,000U 3xlweek)
`
`9
`
`

`

`Patent Application Publication Sep. 1, 2005 Sheet 9 of 11
`
`US 2005/0191298 A1
`
`Figure 8.
`Eculizumab Pharmacodynamics Pre- and Post-dose
`
`140
`
`-;-
`'iii 120
`~
`~
`-
`100
`Z'
`·::;
`~ 80
`<(
`(,)
`~ 60
`0
`E
`CD
`:I:
`E
`2
`CD
`(/)
`
`40
`
`20
`
`0
`
`·2 0 2
`
`10
`
`14
`
`18
`
`22
`
`l:ultzumab
`
`26
`30
`34
`38
`Time (weeks)
`
`42
`
`46
`
`50
`
`54
`
`58
`
`62
`
`Figure 8 shows serum hemolytic activity (PD) during the 64 week treatment
`period as determined by the ability of serum to lyse antibody-presensitized
`chicken erythrocytes. The percentage of hemolytic activity at which complement
`is considered to be effectively inhibited (S 20 %) is indicated by dashed line. Two
`patients that demonstrated trough serum hemolytic activity values less than 20%
`are identified (patients 1 and 2).
`
`10
`
`

`

`Patent Application Publication Sep. 1, 2005 Sheet 10 of 11
`
`US 2005/0191298 A1
`
`Figure 9.
`Eculizumab Pharmacodynamics Pre- and Post-dose
`
`Domain (a)
`
`Mean Base-Line
`Score (b)
`
`Global Health Status
`
`Physical Functioning
`
`Emotional Functioning
`
`Role Functioning
`
`Cognitive Functioning
`
`Fatigue
`
`Dyspnea
`
`Insomnia
`
`Pain
`
`56.1
`
`70.9
`
`70.5
`
`66.7
`
`77.3
`
`47.5
`
`39.4
`
`30.3
`
`21.2
`
`64 Week
`Change from
`Base-line (c)
`13.8
`
`14.3
`
`12.5
`
`14.5
`
`10.3
`
`-17.8
`
`-16.6
`
`-8.2
`
`-8.2
`
`p-value (d)
`
`0.009
`
`<0.001
`
`<0.001
`
`0.003
`
`0.001
`
`<0.001
`
`0.002
`
`0.031
`
`0.023
`
`a)
`
`b)
`c)
`
`d)
`
`<0.001
`4.1
`3.0
`Constipation
`the quality of hfe was assessed usmg the European Organ1zat1on for
`Research and Treatment of Cancer QLQ-C30 instrument
`numbers represent mean values of linearly transformed scores
`values represent least-square means; positive change indicates
`improvement for Global Health Status and Functional Scales while a
`negative change indicates improvement for Symptom Scales
`values are from a mixed analysis-of-covariance model with visit as a fixed
`effect, patient as a random effect, and baseline as a covariate
`
`11
`
`

`

`Patent Application Publication Sep. 1, 2005 Sheet 11 of 11
`
`US 2005/0191298 A1
`
`Figure 10.
`Symptoms Pre- and 2 Years Post-Eculizumab
`
`None
`
`None
`
`-
`
`Every week None
`
`None
`
`None
`
`-
`
`None
`
`None
`
`-
`
`None
`
`None
`
`None
`
`None
`
`None
`
`Pre-Eculizumab
`Post-Eculizumab
`Patien ~bdominal Dysphagia Erectile
`~bdominal Dysphagia Erectile.
`Pain
`Dysfunction Pain
`Dysfunction
`010- Every 4- Every 4- Every 4-8 None
`None
`None
`001
`8 weeks 8 weeks weeks
`-
`010- None
`None
`002
`010- Every
`Every
`003 week
`week
`010- Every 4- None
`004
`6 weeks
`010- None
`006
`010- None
`007
`
`r--
`
`None
`
`None
`
`-
`
`None
`
`Intermittent
`
`None
`
`None
`
`At least
`~very 4
`~eeks
`Every 10 Every 10 None
`~eeks Weeks
`None
`None
`
`010- None
`008
`010- None
`009
`010- Every 4 Every 4 None
`010
`~eeks
`~eeks
`
`011- None
`001
`011- None
`003
`
`None
`
`None
`
`-
`
`-
`
`None
`
`None
`
`None
`
`None
`
`2
`episodes
`in 2 years*
`None
`
`-
`
`-
`
`None
`
`None
`
`*This patient experienced a transient breakthrough in complement blockade
`with a return of hemolysis and symptoms. Increasing the dosing frequency to
`12 days re-established complete complement blockade and prevented further
`symptoms.
`
`12
`
`

`

`US 2005/0191298 A1
`
`Sep. 1,2005
`
`1
`
`METHOD OF TREATING HEMOLYTIC DISEASE
`
`RELATED APPLICATIONS
`
`[0001] This application is a continuation-in-part of U.S.
`patent application Ser. No. 10/771,552, filed Feb. 3, 2004,
`the entire disclosure of which is incorporated herein by this
`reference.
`
`BACKGROUND
`
`[0002] 1. Technical Field
`
`[0003] This disclosure relates to a method of treating a
`hemolytic disease such as, for example, paroxysmal noctur(cid:173)
`nal hemoglobinuria ("PNH"), by administering a compound
`which binds to, or otherwise blocks, the generation and/or
`activity of one or more complement components.
`
`[0004] 2. Background of Related Art
`
`[0005] Paroxysmal nocturnal hemoglobinuria ("PNH") is
`an uncommon blood disorder wherein red blood cells are
`compromised and are thus destroyed more rapidly than
`normal red blood cells. PNH results from a mutation of bone
`marrow cells resulting in the generation of abnormal blood
`cells. More specifically, PNH is believed to be a disorder of
`hematopoietic stem cells, which give rise to distinct popu(cid:173)
`lations of mature blood cells. The basis of the disease
`appears to be somatic mutations leading to the inability to
`synthesize the glycosyl-phosphatidylinositol ("GPI") anchor
`that is responsible for binding proteins to cell membranes.
`The mutated gene, PIG-A(phosphatidylinositol glycan class
`A) resides in the X chromosome and can have several
`different mutations, varying from deletions to point muta(cid:173)
`tions.
`
`[0006] PNH causes a sensitivity to complement proteins
`and this sensitivity occurs in the cell membrane. PNH cells
`are deficient in a number of proteins, particularly essential
`complement-regulating surface proteins. These comple(cid:173)
`ment-regulating surface proteins include the decay-acceler(cid:173)
`ating factor ("DAF") or CDSS and membrane inhibitor of
`reactive lysis ("MIRL") or CD59.
`
`[0007] PNH is characterized by hemolytic anemia (a
`decreased number of red blood cells), hemoglobinuria (the
`presence of hemoglobin in the urine particularly evident
`after sleeping), and hemoglobinemia (the presence of hemo(cid:173)
`globin in the bloodstream). PNH-afflicted individuals are
`known to have paroxysms, which are defined here as inci(cid:173)
`dences of dark-colored urine. Hemolytic anemia is due to
`intravascular destruction of red blood cells by complement
`components. Other known symptoms include dysphagia,
`fatigue, erectile dysfunction, thrombosis and recurrent
`abdominal pain.
`
`[0008] Hemolysis resulting from hemolytic diseases
`causes local and systemic nitric oxide (NO) deficiency
`through the release of free hemoglobin. Free hemoglobin is
`a very efficient scavenger of NO, due in part to the acces(cid:173)
`sibility of NO in the non-erythrocyte compartment and a 106
`times greater affinity of the heme moiety for NO than that for
`oxygen. The occurrence of intravascular hemolysis often
`generates sufficient free hemoglobin to completely deplete
`haptoglobin. Once the capacity of this hemoglobin scaveng(cid:173)
`ing protein is exceeded, consumption of endogenous NO
`ensues. For example, in a setting of intravascular hemolysis
`
`such as PNH, where LDH levels can easily exceed 2-3 times
`their normal levels, free hemoglobin would likely obtain
`concentrations of 0.8-1.6 g/1. Since haptoglobin can only
`bind somewhere between 0.7 to 1.5 g/1 of hemoglobin
`depending on the haptoglobin allotype, a large excess of free
`hemoglobin would be generated. Once the capacity of
`hemoglobin reabsorption by the kidney proximal tubules is
`exceeded, hemoglobinuria ensues. The release of free hemo(cid:173)
`globin during intravascular hemolysis results in excessive
`consumption of NO with subsequent enhanced smooth
`muscle contraction, vasoconstriction and platelet activation
`and aggregation. PNH-related morbidities associated with
`NO scavenging by hemoglobin include abdominal pain,
`erectile dysfunction, esophageal spasm, and thrombosis.
`
`[0009] The laboratory evaluation of hemolysis normally
`includes hematologic, serologic, and urine tests. Hemato(cid:173)
`logic tests include an examination of the blood smear for
`morphologic abnormalities of RBCs (to determine causa(cid:173)
`tion), and the measurement of the reticulocyte count in
`whole blood (to determine bone marrow compensation for
`RBC loss). Serologic tests include lactate dehydrogenase
`(LDH; widely performed), and free hemoglobin (not widely
`performed) as a direct measure of hemolysis. LDH levels, in
`the absence of tissue damage in other organs, can be useful
`in the diagnosis and monitoring of patients with hemolysis.
`Other serologic tests include bilirubin or haptoglobin, as
`measures of breakdown products or scavenging reserve,
`respectively. Urine tests include bilirubin, hemosiderin, and
`free hemoglobin, and are generally used to measure gross
`severity of hemolysis and for differentiation of intravascular
`vs. extravascular etiologies of hemolysis rather than routine
`monitoring of hemolysis. Further, RBC numbers, RBC (i.e.
`cell-bound) hemoglobin, and hematocrit are generally per(cid:173)
`formed to determine the extent of any accompanying anemia
`rather than as a measure of hemolytic activity per se.
`
`[0010] Steroids have been employed as a therapy for
`hemolytic diseases and may be effective in suppressing
`hemolysis in some patients, although long term use of
`steroid therapy carries many negative side effects. Afflicted
`patients may require blood transfusions, which carry risks of
`infection. Anti-coagulation therapy may also be required to
`prevent blood clot formation. Bone marrow transplantation
`has been known to cure PNH, however, bone marrow
`matches are often very difficult to find and mortality rates are
`high with such procedure.
`
`It would be advantageous to provide a treatment
`[0011]
`which safely and reliably eliminates and/or limits hemolytic
`diseases, such as PNH, and their effects.
`
`SUMMARY
`
`[0012] Paroxysmal nocturnal hemoglobinuria ("PNH")
`and other hemolytic diseases are treated in accordance with
`this disclosure using a compound which binds to or other(cid:173)
`wise blocks the generation and/or activity of one or more
`complement components. Suitable compounds include, for
`example, antibodies which bind to or otherwise block the
`generation and/or activity of one or more complement
`components, such as, for example, an antibody specific to
`complement component CS. In particularly useful embodi(cid:173)
`ments, the compound is an anti-CS antibody selected from
`the group consisting ofh5G1.1-mAb (eculizumab), h5G1.1-
`scFv (pexelizumab) and other functional fragments of
`
`13
`
`

`

`US 2005/0191298 A1
`
`Sep. 1,2005
`
`2
`
`hSGl.l. It has surprisingly been found that the present
`methods provide improvements in the PNH subject within
`24 hours of administration of the compound. For example,
`hemolysis is significantly reduced within 24 hours of admin(cid:173)
`istration of the compound as indicated by resolution of
`hemoglobinuria.
`[0013] The complement-inhibiting compound can be
`administered prophylactically in individuals known to have
`a hemolytic disease to prevent, or help prevent the onset of
`symptoms. Alternatively, the complement-inhibiting com(cid:173)
`pound can be administered as a therapeutic regimen to an
`individual experiencing symptoms of a hemolytic disease.
`[0014]
`In another aspect, a method of increasing the
`proportion of complement sensitive type III red blood cells
`and therefore the total red blood cell count in a patient
`afflicted with a hemolytic disease is contemplated. The
`method comprises administering a compound which binds
`to or otherwise blocks the generation and/or activity of one
`or more complement components to a patient afflicted with
`a hemolytic disease. By increasing type III red blood cell
`count, symptoms such as fatigue and anemia also can be
`alleviated in a patient afflicted with a hemolytic disease.
`[0015]
`In yet another aspect, the present disclosure con(cid:173)
`templates a method of rendering a subject afflicted with a
`hemolytic disease less dependent on transfusions or trans(cid:173)
`fusion-independent by administering a compound to the
`subject, the compound being selected from the group con(cid:173)
`sisting of compounds which bind to one or more comple(cid:173)
`ment components, compounds which block the generation
`of one or more complement components and compounds
`which block the activity of one or more complement com(cid:173)
`ponents. It has surprisingly been found that patients can be
`rendered transfusion-independent in accordance with the
`present methods. Unexpectedly, transfusion-independence
`can be maintained in some embodiments for twelve months
`or more, long beyond the 120 day life cycle of red blood
`cells. In other embodiments, transfusion-independence can
`be maintained for two years or more. Treatment for six
`months or more is required for the evaluation of transfusion
`independence given the long half life of red blood cells.
`
`[0016]
`In another aspect, the present disclosure contem(cid:173)
`plates a method of treating a nitric oxide (NO) imbalance in
`a subject by administering a compound to the subject, the
`compound being selected from the group consisting of
`compounds which bind to one or more complement com(cid:173)
`ponents, compounds which block the generation of one or
`more complement components and compounds which block
`the activity of one or more complement components. By
`reducing the lysis of red blood cells, the present methods
`reduce the amount of free hemoglobin in the bloodstream,
`thereby increasing serum levels of nitric oxide (NO). In
`is
`particularly useful embodiments, NO homeostasis
`restored wherein there is a resolution of symptoms attribut(cid:173)
`able to NO deficiency.
`
`[0017]
`In another aspect, the present disclosure contem(cid:173)
`plates a method of treating thrombosis in a subject by
`administering a compound to the subject, the compound
`being selected from the group consisting of compounds
`which bind to one or more complement components, com(cid:173)
`pounds which block the generation of one or more comple(cid:173)
`ment components and compounds which block the activity
`of one or more complement components.
`
`[0018]
`In another aspect, the present disclosure contem(cid:173)
`plates a method of treating fatigue in a subject afflicted with
`a hemolytic disease by administering a compound to the
`subject, the compound being selected from the group con(cid:173)
`sisting of compounds which bind to one or more comple(cid:173)
`ment components, compounds which block the generation
`of one or more complement components and compounds
`which block the activity of one or more complement com(cid:173)
`ponents.
`
`[0019]
`In another aspect, the present disclosure contem(cid:173)
`plates a method of treating erectile dysfunction in a subject
`afflicted with a hemolytic disease by administering a com(cid:173)
`pound to the subject, the compound being selected from the
`group consisting of compounds which bind to one or more
`complement components, compounds which block the gen(cid:173)
`eration of one or more complement components and com(cid:173)
`pounds which block the activity of one or more complement
`components.
`
`[0020]
`In another aspect, the present disclosure contem(cid:173)
`plates a method of treating abdominal pain in a subject
`afflicted with a hemolytic disease by administering a com(cid:173)
`pound to the subject, the compound being selected from the
`group consisting of compounds which bind to one or more
`complement components, compounds which block the gen(cid:173)
`eration of one or more complement components and com(cid:173)
`pounds which block the activity of one or more complement
`components.
`
`[0021]
`In yet another aspect, the present disclosure con(cid:173)
`templates a method of treating a subject afflicted with a
`hemolytic disease by administering: 1) one or more com(cid:173)
`pounds known to increase hematopoiesis (for example,
`either by boosting production, eliminating stem cell destruc(cid:173)
`tion or eliminating stem cell inhibition) in combination with
`2) a compound selected from the group consisting of com(cid:173)
`pounds which bind to one or more complement components,
`compounds which block the generation of one or more
`complement components and compounds which block the
`activity of one or more complement components. Suitable
`compounds known to increase hematopoiesis include, for
`example,
`steroids,
`immunosuppressants
`(such
`as,
`cyclosporin), anti-coagulants (such as, warfarin), folic acid,
`iron and the like, erythropoietin (EPO) and antithymocyte
`globulin (ATG), antilymphocyte globulin (ALG), EPO
`derivatives, and darbepoetin alfa (commercially available as
`Aranesp® from Arngen, Inc., Thousand Oaks, Calif.
`(Aranesp® is a man-made form of EPO produced in Chinese
`hamster ovary (CHO) cells by recombinant DNA technol(cid:173)
`ogy)). In particularly useful embodiments, erythropoietin
`(EPO) (a compound known to increase hematopoiesis), EPO
`derivatives, or darbepoetin alfa may be administered in
`combination with an anti-CS antibody selected from the
`group consisting of h5G1.1-mAb, h5G1.1-scFv and other
`functional fragments of hSGl.l.
`
`[0022]
`In yet another aspect, the present disclosure con(cid:173)
`templates a method of treating one or more symptoms of
`hemolytic diseases in a subject where the proportion of type
`III red blood cells of the subject's total red blood cell content
`is greater than 10% before or during treatment, by admin(cid:173)
`istering a compound selected from the group consisting of
`compounds which bind to one or more complement com(cid:173)
`ponents, compounds which block the generation of one or
`more complement components and compounds which block
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`
`3
`
`the activity of one or more complement components, said
`compound being administered alone or in combination with
`one or more compounds known to increase hematopoiesis,
`such as EPO, EPO derivatives, or darbepoetin alfa.
`
`[0023]
`In yet another aspect, the present disclosure con(cid:173)
`templates a method of treating one or more symptoms of
`hemolytic diseases in a subject having a platelet count above
`40,000 per microliter, by administering a compound selected
`from the group consisting of compounds which bind to one
`or more complement components, compounds which block
`the generation of one or more complement components and
`compounds which block the activity of one or more comple(cid:173)
`ment components, said compound being administered alone
`or in combination with one or more compounds known to
`increase hematopoiesis, such as EPO, EPO derivatives, or
`darbepoetin alfa.
`
`[0024]
`In yet another aspect, the present disclosure con(cid:173)
`templates a method of treating one or more symptoms of a
`hemolytic diseases in a subject having a reticulocyte count
`above 80xl09 per liter, by administering a compound
`selected from the group consisting of compounds which
`bind to one or more complement components, compounds
`which block the generation of one or more complement
`components and compounds which block the activity of one
`or more complement components, said compound being
`administered alone or in combination with one or more
`compounds known to increase hematopoiesis, such as EPO,
`EPO derivatives, or darbepoetin alfa.
`
`BRIEF DESCRIPTION OF THE DRAWINGS
`
`[0025] FIG. 1A reports biochemical parameters of
`hemolysis measured during treatment of PNH patients with
`an anti-CS antibody.
`
`[0026] FIG. 1B graphically depicts the effect of treatment
`with an anti-CS antibody on lactate dehydrogenase (LDH)
`levels.
`
`[0027] FIG. 2 shows a urine color scale devised to moni(cid:173)
`tor the incidence of paroxysm of hemoglobinuria in PNH
`patients.
`
`[0028] FIG. 3 is a graph of the effects of eculizumab
`treatments on patient paroxysm rates, as compared to pre(cid:173)
`treatment rates.
`
`[0029] FIG. 4 shows urine samples of PNH patients and
`measurements of hemoglobinuria, dysphagia, LDH, AST,
`pharmacokinetics
`(PK) and pharmacodynamics
`(PD)
`reflecting the immediate and positive effects of the present
`methods on hemolysis, symptoms and pharmacodynamics
`suitable to completely block complement.
`
`[0030] FIG. 5 graphically depicts the effect of anti-CS
`antibody dosing schedule on hemoglobinuria over time.
`
`[0031] FIGS. 6a and 6b are graphs comparing the number
`of transfusion units required per patient per month, prior to
`and during treatment with an anti-CS antibody: FIG. 6a
`depicts cytopenic patients; and FIG. 6b depicts non-cy(cid:173)
`topenic patients.
`
`[0033] FIG. 8 graphically depicts the pharmacodynamics
`of an anti-CS antibody.
`
`[0034] FIG. 9 is a chart of the results of European
`Organization for Research and Treatment of Cancer ques(cid:173)
`tionnaires ("EORTC QLC-C30") completed during the anti(cid:173)
`CS therapy regimen addressing quality of life issues.
`
`[0035] FIG. 10 is a chart depicting the effects of anti-CS
`antibody treatments on adverse symptoms associated with
`PNH.
`
`DETAILED DESCRIPTION
`
`[0036] The present disclosure relates to a method of
`treating paroxysmal nocturnal hemoglobinuria ("PNH") and
`other hemolytic diseases in mammals. Specifically, the
`methods of treating hemolytic diseases, which are described
`herein, involve using compounds which bind to or otherwise
`block the generation and/or activity of one or more comple(cid:173)
`ment components. The present methods have been found to
`provide surprising results. For instance, hemolysis rapidly
`ceases upon administration of the compound which binds to
`or otherwise blocks the generation and/or activity of one or
`more complement components, with hemoglobinuria being
`significantly reduced after
`treatment. Also, hemolytic
`patients can be rendered less dependent on transfusions or
`transfusion-independent
`for extended periods
`(twelve
`months or more), well beyond the 120 day life cycle of red
`blood cells. In addition, type III red blood cell count can be
`increased dramatically in the midst of other mechanisms of
`red blood cell lysis (non-complement mediated and/or ear(cid:173)
`lier complement component mediated e.g., Cb3). Another
`example of a surprising result is that symptoms resolved,
`indicating that NO serum levels were increased enough even
`in the presence of other mechanisms of red blood cell lysis.
`These and other results reported herein are unexpected and
`could not be predicted from prior treatments of hemolytic
`diseases.
`[0037] Any compound which binds to or otherwise blocks
`the generation and/or activity of one or more complement
`components can be used in the present methods. A specific
`class of such compounds which is particularly useful
`includes antibodies specific to a human complement com(cid:173)
`ponent, especially anti-CS antibodies. The anti-CS antibody
`inhibits the complement cascade and, ultimately, prevents
`red blood cell ("RBC") lysis by the complement protein
`complex CSb-9. By inhibiting and/or reducing the lysis of
`RBCs, the effects of PNH and other hemolytic diseases
`(including symptoms such as hemoglobinuria, anemia,
`hemoglobinemia, dysphagia, fatigue, erectile dysfunction,
`recurrent abdominal pain and thrombosis) are eliminated or
`decreased.
`[0038]
`In another embodiment, soluble forms of the pro(cid:173)
`teins CDSS and CDS9, singularly or in combination with
`each other, can be administered to a subject to inhibit the
`complement cascade in its alternative pathway. CDSS inhib(cid:173)
`its at the level of C3, thereby preventing the further pro(cid:173)
`gression of the cascade. CDS9 inhibits the CSb-8 complex
`from combining with C9 to form the membrane attack
`complex (see discussion below).
`
`[0032] FIG. 7 shows the management of a thrombocy(cid:173)
`topenic patient by administering an anti-CS antibody and
`erythropoietin (EPO).
`
`[0039] The complement system acts in conjunction with
`other immunological systems of the body to defend against
`intrusion of bacterial and viral pathogens. There are at least
`
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`4
`
`25 proteins involved in the complement cascade, which are
`found as a complex collection of plasma proteins and
`membrane cofactors. Complement components achieve
`their immune defensive functions by interacting in a series
`of intricate but precise enzymatic cleavage and membrane
`binding events. The resulting complement cascade leads to
`the production of products with opsonic, immunoregulatory,
`and lytic functions. A concise summary of the biologic
`activities associated with complement activation is pro(cid:173)
`vided, for example, in The Merck Manual, 16'h Edition.
`
`[0040] The complement cascade progresses via the clas(cid:173)
`sical pathway, the alternative pathway or the lectin pathway.
`These pathways share many components, and while they
`differ in their initial steps, they converge and share the same
`"terminal complement" components (C5
`through C9)
`responsible for the activation and destruction of target cells.
`The classical complement pathway is typically initiated by
`antibody recognition of and binding to an antigenic site on
`a target cell. The alternative pathway is usually antibody
`independent, and can be initiated by certain molecules on
`pathogen surfaces. Additionally, the lectin pathway is typi(cid:173)
`cally initiated with binding of mannose-binding lectin
`("MEL") to high mannose substrates. These pathways con(cid:173)
`verge at the point where complement component C3 is
`cleaved by an active protease to yield C3a and C3b.
`
`[0041] C3a is an anaphylatoxin (see discussion below).
`C3b binds to bacteria and other cells, as well as to certain
`viruses and immune complexes, and tags them for removal
`from the circulation. (C3b in this role is known as opsonin.)
`The opsonic function of C3b is generally considered to be
`the most important anti-infective action of the complement
`system. Patients with genetic lesions that block C3b function
`are prone to infection by a broad variety of pathogenic
`organisms, while patients with lesions later in the comple(cid:173)
`ment cascade sequence, i.e., patients with lesions that block
`C5 functions, are found to be more prone only to Neisseria
`infection, and then only somewhat more prone (Fearon, in
`Intensive Review of Internal Medicine, 2nd Ed. Fanta and
`Minaker, eds. Brigham and Women's and Beth Israel Hos(cid:173)
`pitals, 1983).
`
`[0042] C3b also forms a complex with other components
`unique to each pathway to form classical or alternative C5
`convertase, which cleaves C5 into C5a and C5b. C3 is thus
`regarded as the central protein in the complement reaction
`sequence since it is essential to all three activation pathways
`(Wurzner, et al., Complement Inflamm. 8:328-340, 1991).
`This property of C3b is regulated by the serum protease
`Factor I, which acts on C3b to produce iC3b (inactive C3b).
`While still functional as an opsonin, iC3b can not form an
`active C5 convertase.
`
`[0043] The pro-C5 precursor is cleaved after amino acid
`655 and 659, to yield the beta chain as an amino terminal
`fragment (amino acid residues +1 to 655 of the sequence)
`and the alpha chain as a carboxyl terminal fragment (amino
`acid residues 660 to 1658 of the sequence), with four amino
`acids (amino acid residues 656-659 of the sequence) deleted
`between the two. C5 is glycosylated, with about 1.5-3
`percent of its mass attributed to carbohydrate. Mature C5 is
`a heterodimer of a 999 amino acid 115 kDa alpha chain that
`is disulfide linked to a 655 amino acid 75 kDa beta chain. C5
`is found in normal serum at approximately 75 ,ug!ml (0.4
`,uM). C5 is synthesized as a sin