Volume 30, no. 7
`The Journal of Rheumatology
`Toxicity, pharmacokinetics, and dose-finding study of repetitive treatment with the
`Phasehumanized anti-interleukin 6 receptor antibody MRA in rheumatoid arthritis.
`
`I/II clinical study.
`Norihiro Nishimoto, Kazuyuki Yoshizaki, Keiji Maeda, Taro Kuritani, Hitoshi Deguchi, Bunzo
`Sato, Nobuyuki Imai, Masaki Suemura, Takahiro Kakehi, Nobuhiro Takagi and Tadamitsu
`Kishimoto
`J Rheumatol 2003;30;1426-1435
`http://www.jrheum.org/content/30/7/1426
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`Lassen - Exhibit 1023, p. 1
`
`

`

`Toxicity, Pharmacokinetics, and Dose-Finding
`Study of Repetitive Treatment with the Humanized
`Anti-Interleukin 6 Receptor Antibody MRA in
`NORIHIRO NISHIMOTO, KAZUYUKI YOSHIZAKI, KEIJI MAEDA, TARO KURITANI, HITOSHI DEGUCHI,
`BUNZO SATO, NOBUYUKI IMAI, MASAKI SUEMURA, TAKAHIRO KAKEHI, NOBUHIRO TAKAGI, and
`Rheumatoid Arthritis. Phase I/II Clinical Study
`TADAMITSU KISHIMOTO
`ABSTRACT. Objective.To evaluate the safety and pharmacokinetics of multiple infusions of a humanized anti-
`interleukin-6 (IL-6) receptor antibody, MRA, in patients with rheumatoid arthritis (RA).
`Methods.In an open label trial, 15 patients with active RAwere intravenously administered 3 doses
`(2, 4, or 8 mg/kg) of MRAbiweekly for 6 weeks, and pharmacokinetics were assessed. Patients
`continued on MRAtreatment for 24 weeks, and were then assessed for safety and efficacy.
`Results.The treatment was well tolerated at all doses with no severe adverse event. Increased total
`serum cholesterol was detected as an MRArelated reaction in 10/15 (66%) patients. There was no
`statistically significant difference in the frequency of adverse events among the 3 dose groups. There
`were no new observations of antinuclear antibody or anti-DNAantibody, and no anti-MRAantibody
`was detected. The T1/2increased with repeated doses and as the dose increased. T1/2after the 3rd dose
`of 8 mg/kg reached 241.8 ± 71.4 h. In 12/15 (80%) patients whose serum MRAwas detectable
`during the treatment period, objective inflammatory indicators such as C-reactive protein, erythro-
`cyte sedimentation rate, and serum amyloid Awere completely normalized at 6 weeks, although
`there was no statistically significant difference in efficacy among the 3 dose groups. Nine of 15
`patients achieved ACR 20 at 6 weeks. At 24 weeks, 13 patients achieved ACR 20 and 5 achieved
`ACR 50.
`Conclusion.Repetitive treatment with MRAwas safe and normalized acute phase response in
`patients with RA. Optimal dosing schedule was not defined in this small study, but maintenance of
`serum MRAconcentration seemed important to achieve efficacy. (J Rheumatol 2003;30:1426–35)
`Key Indexing Terms:
`RHEUMATOID ARTHRITIS INTERLEUKIN 6 THERAPY
`HUMANIZED ANTI-IL-6 RECEPTOR ANTIBODY
`Rheumatoid arthritis (RA) is a chronic inflammatory disease
`understood, many cytokines with inflammatory and joint
`characterizedby persistent synovitis and progressive
`destructive properties are involved in the development of
`destruction of cartilage and bone with the presence of
`RA1-3.These inflammatory cytokines are thought to be a
`rheumatoid factors. RAis also associated with systemic
`potential therapeutic target for treatment.
`inflammatory manifestations in addition to local inflamma-
`Interleukin 6 (IL-6) was originally identified as an
`tion of multiple joints. Although the causes are not fully
`antigen-nonspecific B cell differentiation factor produced
`by activated mononuclear cells4, and it has been shown to be
`produced from RAsynovial fibroblasts stimulated by tumor
`necrosis factor (TNF) or IL-13. Most clinical abnormalities
`From the Department of Medical Science I, School of Health and Sport
`in RAcan be accounted for by the unregulated hyperpro-
`Sciences, Osaka University, Osaka; NTTWest Osaka Hospital, Osaka;
`duction of IL-61. It may induce activation of autoreactive T
`Nissei Hospital, Osaka; Labor Welfare Corporation Kansai Rousai
`cells and polyclonal hypergammaglobulinemia and emer-
`Hospital, Hyogo; and Chugai Pharmaceutical Co., Ltd., Tokyo, Japan.
`gence of autoantibodies as a result of B cell differentia-
`Supported by Chugai Pharmaceutical Co., Ltd., Tokyo, Japan.
`tion5–7. IL-6, as a hepatocyte-stimulating factor, may induce
`N. Nishimoto, MD; K. Yoshizaki, MD, M. Suemura, MD; T. Kishimoto,
`MD, Osaka University; K. Maeda, MD; T. Kuritani, MD, NTTWest
`acute phase proteins,resulting in elevation of serum
`Osaka Hospital; H. Deguchi, MD; B. Sato, MD, Nissei Hospital; N. Imai,
`fibrinogen, C-reactive protein (CRP), and amyloid A(SAA)
`MD, Labor Welfare Corporation Kansai Rousai Hospital; T. Kakehi, BSc;
`concentrations, and a decrease in serum albumin8-11. Further,
`N. Takagi, MSc, Chugai Pharmaceutical Co., Ltd.
`Address reprint requests to Dr. N. Nishimoto, Department of Medical
`hyperproduction of IL-6 may cause bone absorption through
`Science I, School of Health and Sport Sciences, Osaka University,
`activation of osteoclasts, resulting in osteoporosis and bone
`2-1 Yamada-oka, Suita-city, Osaka, 565-0871, Japan.
`destruction12. IL-6 may induce thrombocytosis by acting as
`E-mail: norihiro@imed3.med.osaka-u.ac.jp
`Submitted August 12, 2002; revision accepted December 10, 2002.
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`The Journal of on July 18, 2019 - Published by
`Rheumatology
`Personal, non-commercial use only. The Journal of Rheumatology Copyright © 2003. All rights reserved.
`The Journal of Rheumatology 2003; 30:7
`1426
`
`Lassen - Exhibit 1023, p. 2
`
`

`

`to produce
`a megakaryocyte differentiation factor
`tinued at least 4 weeks before the initial MRAadministration. Stable doses
`platelets13,14. Indeed, elevation of IL-6 concentrations has
`of nonsteroidal antiinflammatory drugs and prednisolone (10 mg daily
`been observed in both serum and synovial fluid of patients
`maximum) were allowed. Use of parenteral and/or intraarticular steroid
`with RA15,16. Correlation has been observed between serum
`within 4 weeks before the initial MRAadministration and during the study
`IL-6 levels and clinical and laboratory indices of RA17.
`period were not permitted. Written informed consent was obtained from
`Wendling, et alreported that administration of mouse mono-
`each patient before enrollment. The study was approved by the Ministry of
`Health, Labour and Welfare of Japan and the local ethics committees.
`clonal anti-IL-6 antibody to 5 patients with RAfor 10
`Patients were indemnified by the sponsor of the study, Chugai
`consecutive days resulted in clinical and biological (CRP)
`Pharmaceutical Company Ltd., Tokyo.
`improvement although the improvement was transitory18.
`Study medication and administration.MRAis a humanized anti-human IL-
`Therefore, interference with the action of IL-6 may consti-
`6R Mab of the IgG1 subclass. The antibody was produced by Chugai
`tute a new therapeutic strategy for RA.
`Pharmaceutical Co. Ltd. by continuous fermentation of Chinese hamster
`The IL-6 signal is mediated via the 80 kDa IL-6 receptor
`ovary cells, which had been transfected with cloned DNAcoding for MRA,
`(IL-6R) molecule on the cell surface or the soluble form of
`and was purified from culture supernatant by a series of column chro-
`matography steps. The MRAretains specificity for human IL-6R and is of
`IL-6R (sIL-6R), followed by dimerization of the 130 kDa
`high affinity.The antibody was stored at 4°C in 50 ml vials containing 2.5
`signal transducer gp130, which is bound to the IL-6/IL-6R
`mg MRA/ml.
`complex19,20. MRAis a humanized anti-human IL-6R mono-
`The appropriate amount of MRAwas diluted to a total volume of 500
`clonal antibody (Mab) that inhibits the binding of IL-6 to
`ml in sterile saline and administered intravenously with a 0.2 µm in-line
`IL-6R or sIL-6R. The effect of MRAwas examined in the
`filter.The drug was infused at a rate of about 0.3 ml/min over the first 15
`min of infusion, while the patient’s condition was closely monitored. If
`collagen induced arthritis model with cynomolgus monkeys,
`there was no sign of anaphylactic reaction, the rate of infusion was
`because MRAcrossreacts with monkey IL-6R but not with
`increased. The infusion was performed over a period of 2 h. To ensure
`rodent IL-6R. MRAinhibited the development of arthritis
`safety, patients were carefully monitored during infusion and for at least 1
`and improvedsuch inflammatoryindicatorsas CRP,
`h after completion. During the first 3 doses, patients were under supervi-
`fibrinogen, and erythrocyte sedimentation rate (ESR)21. In a
`sion of the investigator or coinvestigator for at least 24 h after MRAinfu-
`sion.This was an open label, dose-ascending study with 3 dose groups, 2, 4,
`SCID mouse model into which synovial tissues from RA
`patients were implanted, MRAtreatment
`resultedin
`and 8 mg/kg. For each dose, MRAwas administered biweekly for 6 weeks,
`shrinkage of the implanted tissue and significant reductions
`and pharmacokinetics and safety data were collected up to 6 weeks after the
`in the numbers of inflammatory cells and osteoclasts22.
`first dose. The study was started from the lowest dose, 2 mg/kg. Escalation
`With patients’informed consent and approval of the
`to the next dose level was permitted if the previous dose level was satis-
`factory in terms of safety and tolerance as determined by the sponsor after
`Ethical Committee and the Advanced Medical Treatment
`discussion with the sponsor’s medical expert and the investigators or coin-
`Review Board of Osaka University, we treated some
`vestigators. The next higher dose was examined with a group of newly
`patients with refractoryRAwith MRA. The patients
`recruited patients. With patients’consent and if MRAtreatment was well
`received MRAwith stepwise dose escalation, mostly up to
`tolerated and showed an improvement of CRPor ESR compared to base-
`50 mg/patient twice a week, with monitoring for safety.The
`line, patients were allowed to continue MRAtreatment until 24 weeks and
`were then further assessed for safety and efficacy.
`results showed a rapid decrease in CRPto the normal range,
`Assessment of safety and efficacy.Safety was monitored until 4 weeks after
`and alleviation of joint swelling and tenderness23.
`the last dose. Frequency and severity of adverse effects and adverse drug
`Based on these findings, we performed a phase I/II open
`reactions were observed. Clinical and laboratory tests were performed at
`label, dose-ascending trial to evaluate the safety, pharmaco-
`screening, at baseline, on dosing day, at 1 week after every dose, and at 4
`kinetics, and efficacy of repetitive intravenous treatment
`weeks after last dose. For the first 3 doses, clinical and laboratory tests were
`with MRAin patients with established and active RA.
`also performed on the day after each dose and 2 days after each dose.
`Laboratory measurements including a complete blood cell count and ESR
`were performed at each study site. Other laboratory tests were undertaken
`MATERIALS AND METHODS
`by the central laboratory, SRLCo., Ltd. Serum levels of MRAwere
`measured with an enzyme immunoassay using MT18 Mab specific for
`Patients.The study began in August 1999 and ended in August 2000.
`another binding site on IL-6R than that detected by MRAin combination
`Sixteen patients (median age 55 yrs, range 32–72), diagnosed with RAin
`with the sIL-6R. The captured MRAwas detected using a biotinylated Mab
`accord with the 1987 American College of Rheumatology (ACR) criteria
`specific for an epitope in the variable region of MRA, at a dose that does
`and with a history of disease activity for more than 6 months, were enrolled
`not inhibit the binding of IL-6R. The lowest concentration that could be
`(Table 1). They had failed to respond to at least one of the disease-modi-
`reliably detected was 1.0 µg/ml.
`fying antirheumatic drugs (DMARD) or immunosuppressants, or were
`The primary efficacy measurements were the changes in CRPand ESR
`unable to continue the treatments due to adverse reactions. We required
`over time, up to 6 weeks after the first infusion. Other efficacy measures
`patients to have at least 3 swollen joints and at least 6 tender joints, ESR ‡
`were ACR 20, 50, and 70 improvement25and the change over time in ACR
`30 mm/h, serum CRP ‡ 2.0 mg/dl, a white blood cell count ‡ 3500/µl, and
`components up to 4 weeks after the last dose.
`platelet count ‡ 105/µl. Pregnant women, nursing women, and women of
`Statistical methods.For safety analysis, the number of patients who
`childbearing potential not using an effective method of contraception were
`reported adverse events and number of adverse events were recorded for
`excluded. Patients were also excluded if they had severe disability
`each adverse event for each dose group. Incidence rates of adverse events
`(Steinbrocker Class IV)24, a history of a serious allergic reaction, any other
`were calculated with 95% confidence intervals. Pharmacokinetic parame-
`concurrent collagen disease, significant cardiac, blood, respiratory, neuro-
`ters were calculated from serum MRAconcentration data, based on the
`logical, endocrine, renal, hepatic or gastrointestinal disease, or an active
`non-compartment analysis method.
`intercurrent infection. DMARD and immunosuppressants were discon-
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`Rheumatology
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`1427
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`Lassen - Exhibit 1023, p. 3
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`

`

`Table 1. Characteristics of the patients at entry.
`MRADose, mg/kg
`2
`Total
`8
`4
`5
`No. of patients
`15
`5
`5
`55 (40–61)
`Age, yrs, median (range)
`55 (32–72)
`54 (40–63)
`55 (32–72)
`1:4
`Sex, M:F
`4:11
`2:3
`1:4
`10 (4–16)
`Duration of disease, yrs, median (range)
`7 (1–25)
`6 (1–8)
`4 (2–25)
`5 (3–7)
`No. of failed DMARD, median (range)
`4 (2–7)
`4 (2–6)
`4 (2–6)
`26 ± 17
`Tender joint counts, mean ± SD*
`24 ± 14
`26 ± 16
`20 ± 11
`19 ± 10
`Swollen joint counts, mean ± SD*
`21 ± 10
`23 ± 12
`19 ± 9
`92 ± 24
`ESR, mm/h, mean ± SD
`92 ± 27
`76 ± 24
`87 ± 25
`6.9 ± 4.5
`CRP, mg/dl, mean ± SD
`5.3 ± 2.4
`5.4 ± 1.8
`5.9 ± 3.0
`WBC, per µl, mean ± SD
`8646 ± 3068 10722 ± 161910506 ± 2853
`9958 ± 2587
`Platelets, 104/µl, mean ± SD
`30.8 ± 4.5
`32.8 ± 11.5
`48.0 ± 13.7
`37.2 ± 12.7
`*Tender joint count was assessed with 49 joints (maximum joint count was 49). Swollen joint count was assessed
`with 46 joints (maximum joint count was 46). All values were mean ± SD. DMARD: disease modifying anti-
`rheumatic drugs, ESR: erythrocyte sedimentation rate (Westergren); CRP: C-reactive protein, WBC: white blood
`cell count.
`withdrawn. Atotal of 15 patients were included in the
`For the efficacy analysis, changes in each of the ACR components, such
`analysis. Demographic and clinical data at the entry period
`as CRP, ESR, swollen joint counts, tender joint counts, modified Health
`are summarized in Table 1. The median age was 55 years
`Assessment Questionnaire score, physician’s global assessment, patient’s
`(range 32–72 yrs) and the median duration of RAwas 7
`global assessment, and patient’s pain assessment, from baseline for each
`years (range 1–25). The patients had a mean of 24 tender
`dose group were analyzed by paired t tests, and mean changes from base-
`joints (range 8–41) and 21 swollen joints (range 10–35).
`line among the dose groups were analyzed by t tests. The dose relationship
`was analyzed by appropriate statistical procedures such as Jonckheere’s test
`There were no clinically significant differences among all
`for trends. Significance was set at p < 0.05.
`the dose groups.
`RESULTS
`Safety.Treatment tolerance of MRAwas good. Atotal of
`Patients.Sixteen patients were enrolled in the study; their
`132 adverse events were reported in all 15 patients analyzed
`disposition is illustrated in Figure 1. After enrollment, one
`for safety (Table 2 describes adverse events appearing in
`patient in the 8 mg/kg group was found to have a chest
`more than 2 patients). In the 2, 4, and 8 mg/kg groups, there
`radiograph abnormality and was thus ineligible and was
`
`Figure 1.Disposition of patients through the stages of the study. *Patient was found to be ineligible for study
`because of a chest radiograph abnormality and was withdrawn before dosing.
`
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`The Journal of Rheumatology 2003; 30:7
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`1428
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`Lassen - Exhibit 1023, p. 4
`
`

`

`Table 2. Adverse events (reported in more than 2 patients in this study).
`MRADose, mg/kg
`Total
`8
`2
`4
`5
`No. of patients
`5
`5
`Blood and lymphatic system disorder
`2
`1
`Iron deficiency anemia
`0
`1
`General disorder and administration site condition
`3
`2
`0
`1
`Pyrexia
`Infection and infestations
`5
`0
`3*
`2**
`Nasopharyngitis
`4
`2*
`Tinea blanca
`0
`2*
`2
`1
`Blister
`0
`1*
`Metabolism and nutrition disorder
`6
`2
`Iron metabolism disorder
`1
`3
`Musculoskeletal connective tissue and bone disorder
`2
`1*
`Back pain
`1
`0
`Skin/subcutaneous tissue disorder
`2
`2*
`Contact dermatitis
`0
`0
`2
`1
`Dermatitis NOS
`1*
`0
`2
`0
`Urticaria NOS
`2**
`0
`Investigation
`3
`0
`Alanine aminotransferase increased
`2
`1
`2
`0
`Aspartate aminotransferase increased
`1
`1
`10
`4*
`Blood cholesterol increased
`4*
`2*
`6
`0
`Blood glucose increased
`4
`2
`2
`0
`Blood iron decreased
`0
`2
`5
`0
`Blood LDH increased
`2
`3
`2
`0
`Blood pressure increased
`1*
`1
`3
`0
`Blood thrombin abnormal
`1
`2
`5
`2*
`Blood triglyceride increased
`2
`1
`3
`0
`Blood urea increased
`2
`1
`2
`0
`Glycosuria present
`1
`1
`3
`1
`Hematuria present
`1
`1
`1
`2
`7
`Low density lipoprotein increased
`4
`1
`0
`2
`Leukocyte count decreased
`1
`0
`0
`2
`Leukocyte count increased
`2**
`1
`0
`2
`White blood cells in urine
`1
`* Severity was moderate. ** Severity of one of 2 events was moderate. NOS: not otherwise specified, LDH:
`lactate dehydrogenase.
`In the abnormal laboratory findings, lipid metabolism
`were 55, 51, and 26 adverse events, respectively.All adverse
`events were mild or moderate in severity.Asingle serious
`related reactions such as an increase in blood total choles-
`adverse event, herpes zoster, was reported in one patient.
`terol, low density lipoprotein (LDL), and triglyceride were
`This was resolved by medication, and the patient continued
`frequently observed, although they became stable at a
`the study.
`certain level and did not continue to increase (Figure
`Atotal of 70 adverse events for which a causal relation-
`2E–2G). The total cholesterol and LDLcholesterol levels
`ship with MRAcould not be ruled out (i.e., adverse reaction)
`decreased at 24 weeks in the 2 mg/kg group, but there was
`were observed in 14 of the 15 patients. During the study
`no statistically significant difference. There was no observa-
`period, 37, 20, and 13 adverse reactions were reported in the
`tion of cardiovascularcomplicationsduring the study
`2, 4, and 8 mg/kg groups, respectively. Some of the clinical
`period. Leukocyte and neutrophil counts decreased after
`laboratory tests showed dose-dependent changes, but no
`MRAadministration in all dose groups, but most were
`clear relationship between dose and frequency of adverse
`within normal range. Two patients showed decrease in
`reaction was observed. There were 13 adverse events related
`leukocyte counts below the normal range, and one of them,
`to skin and subcutaneous tissue disorders (dermatitis, etc.),
`in the 2 mg/kg group, had transient, grade 3 neutropenia
`but no reactionsat the injectionsite were reported.
`(neutrophil count < 1000/µl) a day after MRAinfusion.
`Symptoms associated with the common cold were reported
`There were no serious infections associated with transient
`in 5 patients.
`neutropenia. The patient did not show neutropenia again
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`Rheumatology
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`1429
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`Lassen - Exhibit 1023, p. 5
`
`

`

`Figure 2.Change of ACR components (A–D) and laboratory variables (E–H) in MRAtreated
`RApatients. Values are mean ± SD.
`detected, although most of the patients had circulating
`during the treatment period. Adecrease in serum ferritin
`concentration was described as iron metabolism disorder,
`concentrations of MRA, which made it difficult to detect
`but it was associated with an increase in hemoglobin
`anti-MRAantibodies. Antinuclear antibody and anti-DNA
`concentrations, thus indicating effective utilization of iron to
`antibody were not observed in any patient.
`hemoglobin synthesis. An increase in blood lactate dehy-
`Pharmacology.The individual serum MRAconcentrations
`drogenase was noted in 4 patients. The abnormal laboratory
`of this study are shown in Figure 3. Serum MRAconcentra-
`findings did not always persist, and the majority of them
`tion was always detectable during the study period in 4 out
`spontaneously returned to normal range during the study
`of 5 patients in the 2 mg/kg group, and 3 out of 5 patients in
`period.No allergic reaction related to MRAinjection was
`the 4 mg/kg group. In the 8 mg/kg group, serum MRA
`concentration could be detected in all periods in all patients.
`observed in any patient. Anti-MRAantibodies were not
`The mean area-under-the-curve (AUC) and T1/2values
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`Rheumatology
`Personal, non-commercial use only. The Journal of Rheumatology Copyright © 2003. All rights reserved.
`The Journal of Rheumatology 2003; 30:7
`1430
`
`Lassen - Exhibit 1023, p. 6
`
`

`

`Figure 3.MRAconcentration in the sera of patients. MRAwas administered intravenously at
`Weeks 0, 2, and 4. Serum samples were collected before each infusion, at 1 hour after the end
`of each infusion, at 2 days after each infusion, at 1 week after each infusion, and at 6 weeks
`after initial infusion. The lowest level that could be reliably detected was 1.0 µg/ml. All values
`are mean ± SD.
`objective markers improved markedly in the patients whose
`are shown in Figure 4. The AUC for the first dose increased
`serum MRAat the trough levels was detectable, whereas
`as the dose increased and the values (mean ± SD) were 3.44
`± 8.22, 4.66 ± 2.18, and 10.66 ± 4.07 mg*h/ml in the 2, 4,
`CRP, SAA, and fibrinogen were not completely normalized
`and 8 mg/kg groups, respectively.The serum MRAconcen-
`in the patients whose serum MRAconcentrations at trough
`tration decreased in a nonlinear manner with the dose range
`levels were below the quantification limit throughout the
`from 2 to 8 mg/kg. The T1/2for the first dose increased as the
`study period.
`dose increased; the values (mean ± SD) were 74.4 ± 18.3,
`The baseline serum albumin values were below low-
`96.9 ± 50.2, and 160.2 ± 34.3 h in the 2, 4, and 8 mg/kg
`normal range (< 4.0 g/dl) in 12 out of 15 patients, and also
`groups, respectively. Multiple infusion also prolonged the
`at a low limit (4.1 or 4.2 mg/dl) in the remaining 3. This
`T1/2, and after the 3rd dose in the 8 mg/kg group reached
`variable showed marked increases, and normalized at 14
`241.8 ± 71.4 h.
`weeks at all doses (Figure 2H).
`Rheumatoid factors also decreased, from 448.8 ± 431.7
`Clinical efficacy.The mean values of inflammatory indica-
`IU/ml at baseline to 176.4 ± 250.4 IU/ml at 14 weeks in the
`tors such as CRPand ESR are shown in Table 3 and Figures
`8 mg/kg group (p = 0.043 vs baseline).
`2Aand 2B. Baseline CRPvalues were 6.9 ± 4.5, 5.3 ± 2.4,
`The decrease in disease activity is shown in Table 3 and
`and 5.4 ± 1.8 mg/dl (mean ± SD) in the 2, 4, and 8 mg/kg
`Figures 2C and 2D. The baseline swollen joint counts were
`groups, respectively.At 2 weeks after the initial MRAdose,
`19 ± 10, 23 ± 12, and 19 ± 9 (mean ± SD) in the 2, 4, and 8
`these values decreased to 1.0 ± 0.9 (p = 0.041 vs baseline),
`mg/kg groups, respectively.At 14 weeks, these values
`2.2 ± 3.0 (p = 0.028 vs baseline), and 0.2 ± 0.2 mg/dl (p =
`decreased to 12 ± 10, 8 ± 6 (p = 0.009 vs baseline), and 8 ±
`0.002 vs baseline), respectively. In the 8 mg/kg group, CRP
`4 (p = 0.045 vs baseline); and at 24 weeks, to 10 ± 8 (p =
`was normal 2 weeks after initial MRAdose. The baseline
`0.049 vs baseline), 7 ± 6 (p = 0.028 vs baseline), and 5 ± 4
`ESR values were 92 ± 24, 92 ± 27, and 76 ± 24 mm/h,
`(p = 0.017 vs baseline), respectively (Figure 2C). The base-
`respectively.At 2 weeks, these values decreased to 49 ± 18
`line tender joint counts were 26 ± 16, 26 ± 16, and 20 ± 11
`(p = 0.004 vs baseline), 48 ± 34 (p = 0.003 vs baseline), and
`in the 2, 4, and 8 mg/kg groups, respectively.These values
`15 ± 12 mm/h (p = 0.002 vs baseline), respectively. Similar
`decreased to 13 ± 13, 11 ± 14, and 8 ± 5 at 14 weeks; and to
`changes were observed in other inflammatory measures. At
`12 ± 14, 9 ± 10, and 8 ± 4 at 24 weeks (Figure 2D). During
`24 weeks, these inflammatorymeasureswere further
`these periods, the decrease in tender joint counts was statis-
`improved.
`Interestingly,
`fibrinogen
`concentrations
`tically significant in the 8 mg/kg group (p = 0.030 and p =
`decreased only to the low-normal range (data not shown).
`0.028 vs baseline, respectively). Other ACR components
`Figure 5 shows individual change from baseline in each
`also improved with the MRAtreatment. No significant
`inflammatory measure 6 weeks after initial dose. These
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`complications. Thus, repetitive treatment with MRAat up to
`8 mg/kg biweekly intravenous administration was well
`tolerated. In the abnormal laboratory data, lipid metabolism
`abnormalities such as total blood cholesterol, LDL, and
`triglycerideincreaseswerefrequentlyobserved.T h i s
`finding supports reports that serum cholesterol decreased
`following administration of recombinant human IL-6 in
`patients with breast cancer and those with lung cancer26,27.
`E t t i n g e r,et alalso reported that IL-6 might suppress
`apolipoprotein synthesis or secretion28.The inhibition of IL-
`6 action in the lipid metabolism by MRAmight activate
`apolipoprotein synthesis or secretion, and consequently
`increase total serum cholesterol and LDL. Another possible
`explanation is that an increase in total cholesterol may be
`due to improvement in nutrition or to excessive food intake
`in response to the decrease in their disease activity.
`Recently, IL-6 deficient mice were reported to show mature-
`onset obesity — an increase in body fat and in triglyceride
`and very low density lipoprotein in the blood — due to
`suppressed energy expenditure and increased food intake29.
`Therefore, IL-6 must be an important regulator for lipid
`metabolism. To date, we do not know whether this phenom-
`enon is specific to IL-6 inhibition in RA. Since high total
`cholesterol is a risk factor for ischemic heart diseases,
`longterm followup of patients will be required to define the
`safety of MRAtreatment. The hypoalbuminemia observed
`as an acute phase reaction was also ameliorated by MRA
`administration. Considered together with the increase in
`apolipoprotein, the inhibition of IL-6 action may alleviate
`the malnutrition due to cachexia in which constitutive over-
`production of IL-6 is thought to play an important role30.
`With repetitive treatment, MRAaccumulated in patients’
`sera and the T1/2was prolonged at all doses. Thus, it should
`be possible to extend the interval of MRAadministration in
`repetitive treatment for RA. Further, the advantage of a
`Figure 4.Pharmacokinetic variables in MRAtreated RApatients. Values
`are mean ± SD. There was no significant difference between each dose or
`humanized antibody was emphasized in the repetitive treat-
`dosing time.
`ment, because there were no allergic reactions related to
`difference among the treatment groups was observed in the
`MRAinjection and no anti-MRAantibodies were detected
`changes of the ACR components.
`in any patient, none of whom were taking immunosuppres-
`Improvement rates of the ACR criteria are illustrated in
`sive agents such as methotrexate.
`Figure 6. Nine out of 15 patients achieved the ACR 20 at 6
`Strong therapeutic efficacy of MRAfor established RA
`weeks. Two out of 15 patients achieved ACR 50 at 6 weeks.
`was demonstrated in terms of the ACR criteria as outcome
`No patient achieved the ACR 70 at 6 weeks in any dose
`measures. The improvement rate for ACR 20 during the
`group. At 24 weeks, 13 of 15 patients (> 80%) reached ACR
`entire study period was more than 80% and that of ACR 50
`20, 5 of 15 patients (33%) achieved ACR 50, and 2 of 15
`was 33%. Although this was an open label study, the
`patients (13%) achieved ACR 70. There was no evidence of
`improvement in the inflammatory markers such as CRPand
`a statistically significant difference in efficacy among the 3
`ESR clearly indicates the efficacy of MRA.
`dose groups.
`Other inflammatory cytokines such as TNF-aand IL-1ß
`reportedly induce the acute phase proteins in vitro. But
`DISCUSSION
`neither T N F -ainhibitornor IL-1 receptorantagonist
`This is the first report of repetitive dosage with MRAfor the
`completely normalized CRPand ESR concentrations in vivo
`treatment of RA. Although a total of 70 adverse reactions
`in patients with RA31-35. In this study, MRAcompletely
`were reported in the 14 patients during the 24 week treat-
`normalized CRP, SAA, and fibrinogen in the RApatients as
`ment, none was severe and there were few infectious
`long as their serum MRA concentrations
`remained
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`1432
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`Lassen - Exhibit 1023, p. 8
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`

`

`Table 3. Mean values of ACR component at baseline, Week 2, Week 14, and Week 24 after MRAtreatment.
`Variable
`Baseline
`Week 2
`Week 14
`Week 24
`CRP, mg/dl
`2 mg/kg dose
`6.9 ± 4.5
`1.0 ± 0.9*
`0.6 ± 1.2*
`0.7 ± 0.9*
`4 mg/kg
`5.3 ± 2.4
`2.2 ± 3.0*
`1.3 ± 1.9*
`0.3 ± 0.5*
`8 mg/kg
`5.4 ± 1.7
`0.2 ± 0.2*
`0.1 ± 0.1*
`0.1 ± 0.1*
`ESR, mm/h
`2 mg/kg dose
`92 ± 24
`49 ± 18*
`19 ± 12*
`22 ± 9*
`4 mg/kg
`91 ± 27
`48 ± 34*
`34 ± 27*
`23 ± 15*
`8 mg/kg
`76 ± 24
`15 ± 12*
`10 ± 6*
`10 ± 6*
`Swollen joint count
`2 mg/kg dose
`19 ± 10
`16 ± 12
`12 ± 10
`10 ± 8*
`4 mg/kg
`23 ± 12
`17 ± 13*
`8 ± 6*
`7 ± 6*
`8 mg/kg
`19 ± 9
`19 ± 8
`8 ± 8*
`5 ± 4*
`Tender joint count
`2 mg/kg dose
`26 ± 16
`22 ± 17
`13 ± 13*
`12 ± 14
`4 mg/kg
`26 ± 16
`22 ± 16
`11 ± 14
`9 ± 10
`8 mg/kg
`20 ± 11
`19 ± 10
`8 ± 5*
`8 ± 4*
`Physician global assessment**
`2 mg/kg dose
`7.9 ± 1.3
`6.2 ± 2.5*
`3.0 ± 1.1*
`2.6 ± 1.4*
`4 mg/kg
`7.4 ± 2.0
`6.0 ± 2.0
`4.0 ± 2.0
`4.2 ± 2.2
`8 mg/kg
`8.2 ± 1.7
`6.8 ± 2.3
`5.0 ± 1.7*
`3.7 ± 2.6*
`Disability index (MHAQ†)
`2 mg/kg dose
`1.0 ± 0.6
`1.7 ± 0.7
`0.7 ± 0.4*
`0.7 ± 0.5
`4 mg/kg
`1.3 ± 0.8
`1.1 ± 0.7
`0.6 ± 0.4
`0.6 ± 0.4
`8 mg/kg
`1.0 ± 0.6
`0.7 ± 0.3
`0.6 ± 0.4
`0.4 ± 0.3
`Pain**2 mg/kg dose
`7.1 ± 2.0
`5.8 ± 3.7
`2.7 ± 1.6*
`2.9 ± 1.8*
`4 mg/kg
`7.1 ± 1.6
`6.2 ± 1.5
`4.0 ± 2.3
`3.1 ± 1.4*
`8 mg/kg
`6.5 ± 2.0
`5.3 ± 2.3
`3.6 ± 2.4*
`3.2 ± 2.3*
`Patient global assessment**
`2 mg/kg dose
`8.1 ± 1.8
`6.3 ± 2.9
`2.8 ± 1.2*
`3.1 ± 2.0*
`6.2 ± 1.7
`4.0 ± 1.8*
`2.9 ± 1.5*
`4 mg/kg
`7.8 ± 1.9
`5.4 ± 2.4*
`3.6 ± 2.3*
`3.4 ± 2.6*
`8 mg/kg
`7.1 ± 1.9
`* p < 0.05 (paired t test) vs baseline of each assessment. ** Visual analog scale (0 = best, 10 = worst). †Modified
`Health Assessment Questionnaire (0 = best, 3 = worst). All values were mean ± SD. CRP: C-reactive protein,
`ESR: erythrocyte sedimentation rate.
`complex in sera before treatment. Since MRAbinds to IL-
`detectable. These results indicate that IL-6 is a major
`cytokine responsible for acute phase protein production in
`6R, and the immune complex of MRAand IL-6R is cleared
`vivoin patients with RA. At the same time, MRAwas shown
`by the complement pathway, these patients may rapidly
`to be useful for the treatment of secondary amyloidosis, an
`clear immune complexes. However, they also showed
`important complication in Oriental patients, because only a
`significant improvement when they received treatment with
`therapy that successfully reduces the supply of amyloid
`8 mg/kg MRAbiweekly after the study periods (data not
`fibril protein precursors results in substantial regression of
`shown).We need to address the question whether MRAcan
`amyloid36.
`The optimal dosing sc