RU2793745C2 - Methods for treatment or prevention of asthma by administration of il-4r antagonist - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: disclosed use of an antibody or an antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) for the treatment of a subject suffering from oral corticosteroid (OCS) dependent asthma, which includes administering to the subject a loading dose of the antibody or an antigen-binding fragment thereof; and administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, wherein the maintenance doses are administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and an OCS maintenance phase, and wherein the antibody or antigen-binding fragment thereof comprises three sequences of complementarity determining regions (CDRs) of the heavy chain, including SEQ ID NO: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NO: 6, 7 and 8, respectively (options).

EFFECT: effect of the group of inventions is the safety and efficacy of therapy that prevents exacerbations and impaired lung function, improves asthma symptoms and control, and also reduces or eliminates the need for oral glucocorticoids.

21 cl, 48 dwg, 14 tbl, 6 ex

Description

RELATED APPLICATIONS

The present application claims priority over Provisional Applications for U.S. Patent No. 62/579,120, filed October 30, 2017; 62/710381 filed February 16, 2018; 62/647368, filed March 23, 2018; 62/742736, filed October 8, 2018, and European Patent Application No. EP18305566.4, filed May 4, 2018, each of which is incorporated herein by reference in its entirety.

FIELD OF TECHNOLOGY TO WHICH THE INVENTION RELATES

The present invention relates to the treatment and/or prevention of asthma and related conditions. In particular, the present invention relates to the administration of an interleukin-4 receptor (IL-4R) antagonist for the treatment or prevention of asthma in a patient in need thereof.

BACKGROUND OF THE INVENTION

Asthma is a chronic inflammatory disease of the airways characterized by airway hypersensitivity, acute and chronic bronchospasm, edema, and airway obstruction with mucus. The inflammatory component of asthma is thought to involve many cell types, including mast cells, eosinophils, T-lymphocytes, neutrophils, and epithelial cells, as well as their biological products. Patients with asthma most commonly present symptoms of wheezing, shortness of breath, coughing, and chest tightness. For most patients with asthma, a regimen of control medication and bronchodilator therapy provides adequate long-term control. Inhaled corticosteroids (ICS) are considered the "gold standard" in controlling asthma symptoms, and inhaled beta-2 agonists are the most effective bronchodilators currently available. Studies have shown that combination therapy of ICS with a long-acting inhaled beta-2-agonist (LABA) provides better control of asthma than high doses of ICS alone. Therefore, combination therapy was the recommended treatment for subjects who failed to achieve control with low doses of ICS alone.

However, an estimated 5% to 10% of the population has symptomatic asthma despite the maximum recommended treatment with combinations of anti-inflammatory drugs and bronchodilators. In addition, this population with severe asthma accounts for up to 50% of all health care costs during hospitalization, the use of emergency services and unscheduled doctor visits. There is an unmet need for a new therapeutic agent in this severe asthma population because many of these patients respond poorly to ICS due to a number of cellular and molecular mechanisms. In addition, the long-term side effects of systemic and inhaled corticosteroids on bone metabolism, adrenal function, and growth in children lead to attempts to minimize the amount of corticosteroid consumption. Although most patients with asthma are adequately controlled with existing therapies, in patients with severe, uncontrolled asthma (eg, severe corticosteroid-resistant asthma or steroid-intolerant asthma), there are few therapeutic treatment options that can control the disease at the proper level. Unresponsiveness to therapy or non-adherence to therapy results in loss of asthma control and eventually exacerbation of asthma.

An estimated 45% of patients with severe asthma require systemic glucocorticoids to control their disease and prevent life-threatening exacerbations associated with increased risk of irreversible lung tissue damage, progressive persistent airway obstruction, and accelerated decline in lung function. However, systemic glucocorticoids act non-selectively and are associated with significant multi-organ toxicity and extensive immunosuppression. There is a need for safer and more effective targeted therapies that prevent exacerbations and lung dysfunction, improve asthma symptoms and control, and reduce or eliminate the need for oral glucocorticoids.

Approximately 20% of patients with asthma have moderate to severe uncontrolled disease with recurrent exacerbations and persistent symptoms despite maximum standard treatment with control medications. This population is at increased risk of morbidity (particularly exacerbations) and costs significant health care resources. These patients are characterized by significantly reduced lung function despite maximal treatment and are destined to inevitably lose lung function later on. None of the currently approved treatments has been shown to slow this inevitable decline in these patients or to consistently and significantly improve lung function.

Accordingly, there is a need in the art for new targeted therapies for the treatment and/or prevention of asthma.

BRIEF DESCRIPTION OF THE INVENTION

In one aspect, a method is provided for treating a subject suffering from severe, uncontrolled asthma (e.g., severe steroid-dependent asthma), comprising administering to the subject a loading dose of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R), and administering to the subject a plurality of supportive doses of the antibody or antigen-binding fragment thereof, wherein a plurality of maintenance doses are administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and an OCS maintenance phase.

In certain exemplary embodiments, a maintenance dose of the antibody or antigen-binding fragment thereof is administered once every two weeks (q2w). In certain exemplary embodiments, a maintenance dose of the antibody or antigen-binding fragment thereof is administered every four weeks (q4w).

In certain embodiments, a loading dose is administered to the subject and a maintenance dose is administered according to a dosing schedule of 500 mg q4w or 750 mg q4w.

In certain embodiments, a loading dose is omitted. In certain embodiments, the subject is dosed according to a dosing schedule of 500 mg q4w or 750 mg q4w.

In certain exemplary embodiments, the loading dose is approximately 600 mg of the antibody or antigen-binding fragment thereof and/or each maintenance dose of the antibody or antigen-binding fragment thereof is approximately 300 mg of the antibody or antigen-binding fragment thereof.

In certain exemplary embodiments, maintenance doses of the antibody or antigen-binding fragment thereof are administered for at least 24 weeks.

In certain exemplary embodiments, the first maintenance dose of the antibody or antigen-binding fragment thereof is administered two weeks after the loading dose of the antibody or antigen-binding fragment thereof.

In certain exemplary embodiments, the duration of the OCS decline phase is approximately 16 weeks.

In certain exemplary embodiments, the subject's use of OCS is reduced during the OCS declining phase. In certain illustrative embodiments, the subject uses 50% or less, 75% or less, or 90% or less OCS in the maintenance phase as compared to the induction phase. In certain exemplary embodiments, the maintenance phase application of OCS by a subject is reduced to about 5 mg/day or less. In other exemplary embodiments, OCS is reduced and/or eliminated, eg, the subject is tapered off a previous dose of OCS. In certain illustrative embodiments, the administration of OCS is completely excluded from the treatment regimen.

In certain exemplary embodiments, the subject has a blood eosinophil count of about 150 cells/µl or less. In certain exemplary embodiments, the subject has a blood eosinophil count of greater than about 150 cells/µl. In certain exemplary embodiments, the subject has a blood eosinophil count of greater than about 300 cells/µl.

In certain exemplary embodiments, the subject experiences a year-on-year reduction in severe asthma exacerbations. In certain exemplary embodiments, the subject has an improvement in lung function as measured by forced expiratory volume (FEV ₁ ). In other embodiments, the subject has an improvement in lung function in the small airways and/or a decrease in inflammation in the small airways. In certain embodiments, improvement in lung function and reduction in inflammation is measured by forced expiratory flow at 25-75% lung volume (FEF25-75).

In certain exemplary embodiments, the subject's use of OCS is optimized prior to treatment with an antibody or antigen-binding fragment thereof. In certain exemplary embodiments, the OCS is prednisone or prednisolone.

In certain exemplary embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain complementarity determining region (CDR) sequences from a heavy chain variable region (HCVR)/light chain variable region (LCVR) sequence pair comprising SEQ ID NOS: 1 and 2. In certain exemplary embodiments, the antibody or antigen-binding fragment thereof comprises three heavy chain CDR sequences comprising SEQ ID NOs: 3, 4, and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7, and 8, respectively. In certain exemplary embodiments, the antibody or antigen-binding fragment thereof comprises an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and an LCVR comprising the amino acid sequence of SEQ ID NO: 2.

In certain exemplary embodiments, the subject is an adult. In certain exemplary embodiments, the subject is a teenager. In certain exemplary embodiments, the subject is an adult or adolescent, such as 12 years of age or older.

In one aspect, a method is provided for treating a subject suffering from severe uncontrolled asthma (e.g., severe steroid-dependent asthma), comprising administering to the subject a loading dose of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R), and administering to the subject a plurality of maintenance doses of an antibody or antigen-binding fragment thereof, wherein a plurality of maintenance doses are administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and a maintenance phase, and wherein the antibody or antigen-binding fragment thereof comprises heavy and light chain CDR sequences from a pair of HCVR sequences /LCVR, providing SEQ ID NO: 1 and 2.

In another aspect, a method is provided for treating a subject suffering from severe uncontrolled asthma, e.g., severe steroid-dependent asthma, comprising administering to the subject a loading dose of approximately 600 mg of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R), and administering to the subject a plurality of maintenance doses of the antibody or antigen-binding fragment thereof, wherein each maintenance dose is approximately 300 mg of the antibody or antigen-binding fragment thereof, where the plurality of maintenance doses are administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and a maintenance phase, and where the antibody or antigen-binding fragment thereof comprises the heavy and light chain CDR sequences from the HCVR/LCVR sequence pair provided for in SEQ ID NOs: 1 and 2.

In another aspect, a method is provided for reducing the annualized rate of severe exacerbation in a subject with uncontrolled moderate to severe asthma, comprising administering to the subject a q2w or q4w antibody or antigen-binding fragment thereof that specifically binds to IL-4R.

In certain exemplary embodiments, the dose is 200 mg q2w or 300 mg q2w.

In certain exemplary embodiments, a maintenance dose of the antibody or antigen-binding fragment thereof is administered every four weeks (q4w).

In certain embodiments, a loading dose and maintenance doses are administered to the subject, and the subject is dosed according to a dosing schedule of 500 mg q4w or 750 mg q4w.

In certain embodiments, a loading dose is omitted. In certain embodiments, the subject is dosed according to a dosing schedule of 500 mg q4w or 750 mg q4w.

In certain exemplary embodiments, the subject has a blood eosinophil count of less than about 150 cells/µl, greater than about 150 cells/µl, or greater than about 300 cells/µl.

In certain exemplary embodiments, the subject has an exhaled nitric oxide (FeNO) level of about 25 parts per billion (ppb) or greater, has a FeNO level of about 50 ppb or greater, or has a FeNO level of about 25 ppb or more up to about 50 ppb.

In another aspect, a method is provided for improving an FEV ₁ score in a subject with uncontrolled moderate to severe asthma, comprising administering to the subject a q2w or q4w antibody or antigen-binding fragment thereof that specifically binds to IL-4R.

In certain exemplary embodiments, a dose of 200 mg q2w or 300 mg q2w is administered. In certain exemplary embodiments, a dose of 500 mg q4w or 750 mg q4w is administered.

In certain exemplary embodiments, the subject has a blood eosinophil count of less than about 150 cells/µl, greater than about 150 cells/µl, or greater than about 300 cells/µl.

In certain exemplary embodiments, the subject has an exhaled nitric oxide (FeNO) level of about 25 parts per billion (ppb) or greater, has a FeNO level of about 50 ppb or greater, or has a FeNO level of about 25 ppb or more up to about 50 ppb.

In another embodiment, the subject exhibits a decrease of at least 10%, 15%, 20%, or 25% in the level of a biomarker selected from the group consisting of FeNO, eotaxin-3, total IgE, periostin, and thymus-regulated chemokine and activation ( TARC), at week 4, week 12, or week 24 after administration of anti-IL-4R antibody or fragment thereof.

In certain exemplary embodiments, the subject is an adult. In certain exemplary embodiments, the subject is a teenager. In certain exemplary embodiments, the subject is an adult or adolescent, such as 12 years of age or older.

In other aspects, the present invention provides a method for improving a forced expiratory flow rate at 25-75% lung volume (FEF25-75) in a subject suffering from moderate to severe uncontrolled asthma, comprising administering to the subject a q2w or q4w antibody, or an antigen-binding fragment thereof, that specifically bind to IL-4R.

In one embodiment, the dose is 200 mg q2w or 300 mg q2w. In one embodiment, the dose is 500 mg q4w or 750 mg q4w.

In one embodiment, the subject has a blood eosinophil count of less than about 150 cells/µl. In one embodiment, the subject has a blood eosinophil count of about 150 cells/µl or greater. In one embodiment, the subject has a blood eosinophil count of about 300 cells/µl or greater.

In another embodiment, the subject has a FeNO level of about 25 ppb or greater. In another embodiment, the subject has a FeNO level of about 50 ppb or greater. In another embodiment, the subject has a FeNO level of about 25 ppb or more to about 50 ppb.

In another embodiment, the subject has a decrease of at least 10%, at least 15%, at least 20%, or at least 25% in the level of a biomarker selected from the group consisting of FeNO, eotaxin-3, total IgE, periostin and thymus-activated chemokine (TARC) at week 4, week 12, or 24 after administration of anti-IL4R antibody or fragment thereof.

In certain exemplary embodiments, the subject is an adult. In certain exemplary embodiments, the subject is a teenager. In certain exemplary embodiments, the subject is an adult or adolescent, such as 12 years of age or older.

In another aspect, the present invention relates to a method of reducing or eliminating the use of OCS in a subject suffering from severe steroid dependent asthma, the method comprising administering to the subject a loading dose of an antibody or antigen-binding fragment that specifically binds to IL-4R; and administering to the subject a plurality of maintenance doses of the antibody or antigen-binding fragment thereof, wherein a reduction in OCS use of at least 50% or more, at least 75% or more, or at least 90% or more is achieved at week 24 post loading dose.

In one embodiment, the application of OCS is reduced to less than 5 mg per day at week 24 after the administration of the loading dose. In another embodiment, OCS is substantially eliminated over a period of time (eg, 1 year) after administration of a loading dose. In certain embodiments, OCS is substantially eliminated at 40 weeks, 45 weeks, 50 weeks, 52 weeks or more after the first dose following the loading dose.

In one embodiment, a maintenance dose of the antibody or antigen-binding fragment thereof is administered once every two weeks (q2w). In one embodiment, the loading dose is approximately 600 mg of the antibody or antigen-binding fragment thereof. In one embodiment, each maintenance dose of the antibody or antigen-binding fragment is approximately 300 mg of the antibody or antigen-binding fragment. In another embodiment, maintenance doses of the antibody or antigen-binding fragment thereof are administered for at least 24 weeks. In one embodiment, the first maintenance dose of the antibody or antigen-binding fragment thereof is administered two weeks after the loading dose of the antibody or antigen-binding fragment thereof. In one embodiment, the OCS is prednisone or prednisolone.

In one embodiment, the antibody or antigen-binding fragment thereof comprises the heavy and light chain complementarity determining region (CDR) sequences from a heavy chain variable region (HCVR)/light chain variable region (LCVR) sequence pair comprising SEQ ID NOs: 1 and 2. B In one embodiment, the antibody, or antigen-binding fragment thereof, comprises three heavy chain CDR sequences comprising SEQ ID NOs: 3, 4, and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7, and 8, respectively. In one embodiment, the antibody or antigen-binding fragment thereof comprises an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and an LCVR comprising the amino acid sequence of SEQ ID NO: 2.

In certain exemplary embodiments, a maintenance dose of the antibody or antigen-binding fragment thereof is administered every four weeks (q4w).

In certain embodiments, a loading dose is administered to the subject and the subject is dosed according to a dosing schedule of 500 mg q4w or 750 mg q4w.

In certain embodiments, a loading dose is omitted. In certain embodiments, the subject is dosed according to a dosing schedule of 500 mg q4w and 750 mg q4w.

In certain exemplary embodiments, the subject is an adult. In certain exemplary embodiments, the subject is a teenager. In certain exemplary embodiments, the subject is an adult or adolescent, such as 12 years of age or older.

In another aspect, a method is provided for treating a subject suffering from moderate to severe oral corticosteroid (OCS) dependent asthma, comprising administering to the subject a loading dose of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) and administering a subject of multiple maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and multiple maintenance doses are administered as adjunctive maintenance therapy for asthma.

In certain exemplary embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain complementarity determining region (CDR) sequences from a heavy chain variable region (HCVR)/light chain variable region (LCVR) sequence pair comprising SEQ ID NOs: 1 and 2. In certain exemplary embodiments, the antibody or antigen-binding fragment thereof comprises three heavy chain CDR sequences comprising SEQ ID NOs: 3, 4, and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7, and 8, respectively. In certain exemplary embodiments, the antibody or antigen-binding fragment thereof comprises an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and an LCVR comprising the amino acid sequence of SEQ ID NO: 2.

In certain exemplary embodiments, the loading dose is approximately 600 mg of the antibody or antigen-binding fragment thereof. In certain exemplary embodiments, each maintenance dose of an antibody or antigen-binding fragment thereof is approximately 300 mg of the antibody or antigen-binding fragment thereof.

In certain exemplary embodiments, the loading dose is approximately 400 mg of the antibody or antigen-binding fragment thereof. In certain exemplary embodiments, each maintenance dose of an antibody or antigen-binding fragment thereof is approximately 200 mg of the antibody or antigen-binding fragment thereof.

In certain exemplary embodiments, the subject is 12 years of age or older.

In certain exemplary embodiments, the OCS is prednisone or prednisolone.

In another aspect, a method is provided for treating a subject suffering from moderate to severe asthma and associated moderate to severe atopic dermatitis, comprising administering to the subject a loading dose of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R), and administering to the subject a plurality of maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and the plurality of maintenance doses are administered as adjunctive maintenance therapy for asthma.

In another aspect, a method is provided for treating a subject suffering from uncontrolled moderate to severe asthma, where the onset of asthma occurred when the subject was over 40 years of age, comprising administering to the subject a loading dose of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor ( IL-4R), and administering to the subject a plurality of maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and the plurality of maintenance doses are administered as adjunctive maintenance therapy for asthma.

In another aspect, a method is provided for treating a subject suffering from uncontrolled moderate to severe asthma and one or both of concomitant chronic rhinosinusitis and nasal polyposis, comprising administering to the subject a loading dose of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL- 4R), and administering to the subject a plurality of maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and the plurality of maintenance doses are administered as adjunctive maintenance therapy for asthma.

In another aspect, a method is provided for treating a subject suffering from uncontrolled moderate to severe asthma and concomitant allergic rhinitis, comprising administering to the subject a loading dose of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R), and administering to the subject a plurality of maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and multiple maintenance doses are administered as adjunctive maintenance therapy for asthma.

In another aspect, a method is provided for improving allergic rhinitis-related quality of life in a subject suffering from uncontrolled moderate to severe asthma and concomitant allergic rhinitis, comprising administering to the subject a loading dose of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor ( IL-4R), and administering to the subject a plurality of maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and the plurality of maintenance doses are administered as adjunctive maintenance therapy for asthma.

In another aspect, a method is provided for improving quality of life associated with allergic rhinitis in a subject suffering from oral corticosteroid dependent asthma, comprising administering to the subject a loading dose of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R), and administering to the subject a plurality of maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and the plurality of maintenance doses are administered as adjunctive maintenance therapy for asthma.

In certain exemplary embodiments, there is an improvement in daily morning and evening asthma symptom scores.

In certain exemplary embodiments, the oral corticosteroid dependent asthma is oral corticosteroid dependent severe asthma.

In another aspect, a method is provided for improving asthma control in a subject suffering from oral corticosteroid-dependent asthma, comprising administering to the subject a loading dose of an antibody, or antigen-binding fragment thereof, that specifically binds to the interleukin-4 receptor (IL-4R), and administering to the subject a plurality of maintenance doses of the antibody. or an antigen-binding fragment thereof, wherein a loading dose and a plurality of maintenance doses are administered as adjunctive maintenance therapy for asthma.

In certain exemplary embodiments, health-related quality of life is improved.

In certain exemplary embodiments, the oral corticosteroid dependent asthma is oral corticosteroid dependent severe asthma.

Other embodiments will be apparent from a review of the following detailed description, drawings, tables, and appended claims.

BRIEF DESCRIPTION OF GRAPHICS

The foregoing and other features and advantages of the present invention will be better understood from the following detailed description of illustrative embodiments in conjunction with the accompanying drawings. The file of this patent contains at least one graphic material/photograph made in color. Copies of this patent with color(s) graphic(s)/photograph(s) will be provided by the Patent Office upon request and upon payment of the required fee.

In FIG. 1 depicts Venture (EFC13691) phase 3 trial design. EOS denotes end of study, EOT = end of treatment, OCS = oral glucocorticoid, q2w every 2 weeks, R = randomization visit. ^a loading dose of 600 mg (or comparable placebo) on day 1; ^b randomization and first administration of the investigational medicinal product occurs during this visit; ^c The screening period may be extended up to 10 weeks for patients who experience an exacerbation of asthma that requires a change in the dose of glucocorticoids to ensure stabilization for 2 weeks before randomization.

In FIG. 2 is a CONSORT chart showing the distribution of patients for the Venture study (EFC13691).

Fig. 3 is a plot of baseline demographics for the patient population.

In FIG. 4A - fig. 4D is a graphical representation of the primary and secondary endpoints over the 24-week treatment period in the intent-to-treat (ITT) population. In FIG. 4A depicts the primary and secondary end points for oral glucocorticoid at week 24. FIG. 4B shows the annualized rate of severe exacerbations. In FIG. 4C shows the change in FEV ₁ (in litres) prior to bronchodilator administration. In FIG. 4D shows the change in FeNO (in ppb).

In FIG. 5A - fig. 5B depicts results at week 24 by subgroup based on baseline blood eosinophil levels. In FIG. 5A depicts primary endpoint data. In FIG. 5B depicts secondary endpoint data for oral glucocorticoid.

In FIG. 6A-FIG. 6B depicts severe asthma exacerbations (FIG. 6A) and FEV ₁ (l) prior to bronchodilator administration (FIG. 6B) over a 24-week treatment period by subgroup based on baseline blood eosinophil levels.

In FIG. Figure 7 depicts the design of the Quest study for the phase 3 trial.

Fig. 8 represents the distribution of patients for the Quest study.

In FIG. 9A - fig. 9B graphically depicts severe asthma exacerbations in the ITT population and in subgroups defined based on baseline blood eosinophils ≥ 150 and ≥ 300 cells/μL (Fig. 9A) and subgroups defined based on baseline levels of FeNO < 25 ppb, from ≥ 25 to 50 ppb and ≥ 50 ppb (Fig. B).

In FIG. 10A-FIG. 10C depicts changes from baseline in FEV ₁ over time in the ITT population (FIG. 10A) at week 12 in subgroups defined based on baseline blood eosinophils ≥ 150 and ≥ 300 cells/μL (FIG. 10B) and across subgroups. , determined from baseline levels of FeNO < 25 ppb, from ≥ 25 to 50 ppb and ≥ 50 ppb (Fig. 10C).

In FIG. 11A - fig. 11B is a graphical retrospective analysis of severe asthma exacerbations (FIG. 11A) and change from baseline in FEV ₁ (FIG. 11B) in patients with high (≥ 25 ppb) or low (< 25 ppb) baseline FeNO levels and high (≥ 150 cells /µl) or low (<150 cells/µl) initial blood eosinophil count.

In FIG. 12 shows baseline demographics and clinical characteristics of adolescents (n=107) and adults (n=1795). Bold text highlights key differences between subgroups. FeNO - nitric oxide fraction in exhaled air; LABA, long acting β-agonist; SD - standard deviation.

In FIG. 13A-FIG. 13B is a graphical representation of the reduction in severe exacerbations and improvement in FEV ₁ in the general treatment intent (ITT) population. Light gray circles - 1.14 ml placebo; dark gray circles - 2 ml placebo; triangles - 200 mg dupilumab q2w; Xs - 300 mg dupilumab q2w. ***P < 0.001 relative to placebo. CI - confidence interval; LS - least squares method; SE - standard error; arrow - primary end point.

In FIG. 14A-FIG. 14B is a graphical representation of the reduction in severe exacerbation in adolescents and adults. Light gray circles - 1.14 ml placebo; dark gray circles - 2 ml placebo; orange - 200 mg dupilumab q2w; blue - 300 mg dupilumab q2w. ***P < 0.001 relative to placebo; NS - unreliable.

In FIG. 15A-FIG. 15B graphically depicts the improvement in FEV ₁ at week 12 and week 52 in adolescents and adults. Despite higher baseline levels, adolescents were characterized by a large increase in FEV ₁ . *P < 0.05, **P < 0.01, ***P < 0.001 relative to placebo.

In FIG. 16A-FIG. 16B graphically depicts the improvement in FEV ₁ over a 52 week treatment period in adolescents and adults. *P < 0.05, **P < 0.01 relative to placebo.

In FIG. 17 shows that the adverse event profiles were comparable between subgroups (safety assessment population). Eosinophilia is identified as AE with HLT as eosinophilic abnormalities, or PT as elevated eosinophils. HLT is a high level term; PT is the preferred term; SAE - severe adverse event; TEAE is an undesirable phenomenon that appeared during treatment.

In FIG. 18A-FIG. 18B graphically depicts the percent improvement in predicted FEV ₁ over a 52-week treatment period in adolescents and adults. Light gray circles - 1.14 ml placebo; dark gray circles - 2 ml placebo; triangles - 200 mg dupilumab q2w; Xs - 300 mg dupilumab q2w. *P < 0.05, **P < 0.01 relative to placebo.

In FIG. 19A-FIG. 19B graphically depicts FeNO levels over a 52 week treatment period in adolescents and adults. Light gray circles - 1.14 ml placebo; dark gray circles - 2 ml placebo; triangles - 200 mg dupilumab q2w; Xs - 300 mg dupilumab q2w. *P < 0.05, **P < 0.01, ***P < 0.001 relative to placebo.

In FIG. 20A-FIG. 20B graphically depicts ACQ-5 scores over a 52 week treatment period in adolescents and adults. Light gray circles - 1.14 ml placebo; dark gray circles - 2 ml placebo; triangles - 200 mg dupilumab q2w; Xs - 300 mg dupilumab q2w. *P < 0.05, **P < 0.01, ***P < 0.001 relative to placebo.

In FIG. 21A-FIG. 21B graphically depicts AQLQ scores over a 52 week treatment period in adolescents and adults. Light gray circles - 1.14 ml placebo; dark gray circles - 2 ml placebo; triangles - 200 mg dupilumab q2w; Xs - 300 mg dupilumab q2w. *P < 0.05, **P < 0.01, ***P < 0.001 relative to placebo.

In FIG. 22 depicts TEAEs (PT) occurring in ≥ 10% of patients according to subsets of adolescents and adults (safety assessment population).

In FIG. 23 shows information on TEAE, which is conjunctivitis (Safety Assessment Population).

In FIG. 24 shows information on TEAE representing eosinophilia (safety assessment population). Eosinophilia is identified as AE with HLT as eosinophilic abnormalities, or PT as elevated eosinophils.

In FIG. 25A-FIG. 25D depicts the effect of dupilumab over a 24-week treatment period on symptom scores before noon in the ITT population (Fig. 25A) and in the subgroup of patients who had a 100% reduction in OCS by week 24 (Fig. 25B), as well as in in relation to afternoon symptom scores in the ITT population (FIG. 25C) and in the subset of patients who had a 100% reduction in OCS use by week 24 (FIG. 25D). *P< 0.05, ***P< 0.001. SE is standard error. Triangles - placebo; mugs - 300 mg dupilumab q2w.

In FIG. 26A-FIG. 26B depicts the effect of dupilumab on asthma control and HRQoL in patients with OCS-related severe asthma, showing ACQ-5 (FIG. 26A) and total AQLQ (FIG. 26B). *P< 0.05, *P< 0.01, ***P< 0.001. SE is standard error. The minimum clinically significant difference is 0.5 for all scales. Triangles - placebo; mugs - 300 mg dupilumab q2w.

In FIG. 27 shows the effect of dupilumab on severe exacerbation rate, FEV1, and FEV1/FVC ratio in patients with uncontrolled moderate to severe asthma who were > 40 years old at the time of asthma onset and have a baseline FEV1/FVC before bronchodilator administration < 0. 7 or ≥ 0.7.

DETAILED DESCRIPTION

Before describing the present invention, it should be understood that the present invention is not limited to the specific experimental methods and conditions described, as such methods and conditions may vary. It is also to be understood that the terminology used herein is for the purpose of describing specific embodiments only, and is not meant to be limiting, as the scope of the present invention will only be limited by the appended claims.

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as generally understood by a person skilled in the art to which the present invention belongs.

As used herein, the term "approximately", when used with reference to a specific numerical value being described, means that the value may differ from the described value by no more than 1%. For example, as used herein, "about 100" includes 99 and 101 and all values in between (eg, 99.1, 99.2, 99.3, 99.4, etc.).

As used herein, the terms "treat", "treatment", or the like are used herein. means to alleviate symptoms, eliminate the causation of symptoms, either temporarily or permanently, or to prevent or slow down the manifestation of symptoms of said disorder or condition.

Although any methods and materials similar or equivalent to those described herein can be used in the practice of the present invention, typical methods and materials are described below. All publications cited in this document are incorporated herein by reference in their entirety.

Ways to reduce the frequency of asthma exacerbations

The present invention includes methods for reducing the incidence of asthma exacerbations in a subject in need thereof, comprising administering to the subject a pharmaceutical composition containing an IL-4R antagonist. In certain embodiments, an IL-4R antagonist is an antibody, or an antigen-binding fragment thereof, that specifically binds to IL-4R. Illustrative antibodies to IL-4R, which can be used in the context of the methods presented in the present invention, are described in other parts of this document. As used herein, the term "asthma exacerbation" means an increase in the severity and/or frequency of occurrence and/or duration of one or more symptoms or manifestations of asthma. The expression "exacerbation of asthma" also includes any worsening of the subject's respiratory system that requires therapeutic intervention or is to be treated with therapeutic intervention for asthma (such as, for example, steroid treatment, treatment with inhaled corticosteroids, hospitalization, etc.). There are two types of asthma exacerbation events: loss of asthma control (LOAC) event and severe exacerbation event.

In certain embodiments, an asthma loss of control (LOAC) event is defined as one or more of the following: (a) 6 or more additional breath-easing sprays of salbutamol/albuterol or levosalbutamol/levalbuterol over a 24-hour period (compared to baseline) per for 2 consecutive days; (b) increasing the dose of ICS by 4 times or more of the dose at visit 2 and (c) using systemic corticosteroids for 3 days or more or (d) hospitalization or emergency department visit due to asthma requiring systemic corticosteroids .

In certain instances, an asthma exacerbation can be referred to as a "severe asthma exacerbation event". The phenomenon of severe exacerbation of asthma means an event that requires immediate intervention in the form of treatment with either systemic corticosteroids or inhaled corticosteroids at a dose greater than four times or more than the dose taken before this event. In certain embodiments, a severe asthma exacerbation event is defined as a worsening of asthma requiring the following: use of systemic corticosteroids for 3 days or more, or hospitalization or emergency room visit due to asthma requiring systemic corticosteroids. Thus, the general term "asthma exacerbation" includes and encompasses the more specific subcategory of "severe asthma exacerbations". Accordingly, methods of reducing the incidence of severe asthma exacerbations in a patient in need thereof are included.

"Reduced frequency" of an asthma exacerbation means that a subject who has received a pharmaceutical composition containing an IL-4R antagonist has fewer asthma exacerbations (i.e., less by at least one asthma exacerbation) after treatment than before treatment, or not exacerbations of asthma are observed for at least 4 weeks (eg, 4, 6, 8, 12, 14 or more weeks) after the start of treatment with the pharmaceutical composition. "Reducing the frequency" of an asthma exacerbation alternatively means that after administration of the pharmaceutical composition, the likelihood that a subject has an asthma exacerbation is reduced by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35 %, 40%, 45%, 50% or more) compared to a subject who did not receive the pharmaceutical composition.

The present invention includes methods for reducing the frequency of asthma exacerbations in a subject in need thereof, comprising administering to the subject a pharmaceutical composition containing an IL-4R antagonist, as well as administering to the subject one or more maintenance doses of an inhaled corticosteroid (ICS) and/or one or more maintenance doses of a second control a drug, such as a long-acting beta-agonist (LABA) or a leukotriene receptor antagonist (LTA). Suitable ICS include, without limitation, fluticasone (eg, fluticasone propionate, eg, Flovent™), budesonide, mometasone (eg, mometasone furoate, eg, Asmanex™), flunisolide (eg, Aerobid™), dexamethasone acetate/phenobarbital/theophylline (eg, Azmacort™), beclomethasone dipropionate HFA (Qvar™), and the like. Suitable LABAs include, without limitation, salmeterol (eg, Serevent™), formoterol (eg, Foradil™), and the like. Suitable LTAs include, without limitation, montelukast (eg, Singulaire™), zafirlukast (eg, Accolate™), and the like.

The present invention includes methods of reducing the frequency of asthma exacerbations in a subject in need thereof, comprising administering a pharmaceutical composition containing an IL-4R antagonist to the subject, as well as administering to the subject one or more drugs that facilitate breathing to eliminate or reduce one or more asthma-associated symptoms. Suitable breath medications include, but are not limited to, long-acting _beta2 -adrenergic receptor agonists such as, for example, albuterol (eg, salbutamol, eg, Proventil™, Ventolin™, Xopenex™, and the like), pirbuterol (for example, , Maxair™), metaproterenol (eg Alupent™), etc.

Ways to Improve Asthma-Associated Parameters

The present invention also includes methods for improving one or more asthma-associated parameters in a subject in need thereof, wherein the methods comprise administering to the subject a pharmaceutical composition comprising an IL-4R antagonist. Reducing the frequency of asthma exacerbations (as described above) may be associated with an improvement in one or more asthma-associated parameters; however, this relationship is not necessarily observed in all classes.

Examples of "asthma-associated parameters" include (1) relative percentage change from baseline (eg, week 12) in forced expiratory volume in 1 second (FEV ₁ ); (2) relative percentage change from baseline (eg, week 12) as measured by forced expiratory flow at 25-75% lung volume (FEF25-75); (3) the annualized frequency of asthma loss-of-control events during the treatment period; (4) the annualized frequency of severe exacerbation events during the treatment period; (5) time to onset of loss of asthma control events during the treatment period; (6) time to onset of severe exacerbation events during the study period; (7) time to onset of loss of asthma control events throughout the study period; (8) time to onset of severe exacerbation events throughout the study period; (9) use of medical services; (10) change from baseline to week 12 i) morning and evening asthma symptom scores, ii) ACQ-5 score, iii) AQLQ score, iv) morning and evening PEF, v) number of inhalations/day of salbutamol/ albuterol or levosalbutamol/levalbuterol for symptom relief, vi) nocturnal awakenings; (11) change from baseline to week 12 and week 24 i) 22-item nasal and sinus outcome test score (SNOT-22), ii) Hospital Anxiety and Depression Scale (HADS) score, iii ) indicator according to the EuroQual questionnaire (EQ-5D-3L or EQ-5D-5L). "Improvement in an asthma-associated parameter" means an increase from baseline in one or more of FEV ₁ , PEF a.m., or PEF p.m. and/or a decrease from baseline in one or more of daily albuterol/levalbuterol, ACQ5 score, night time or SNOT-22 indicator. As used herein, the term "baseline" in relation to an asthma-associated parameter means the numerical value of the asthma-associated parameter for a patient before or during the entire period of administration of a pharmaceutical composition containing an IL-4R antagonist.

To determine if an asthma-associated parameter has "improved", the parameter is quantified at baseline and at a time point following administration of the pharmaceutical composition described herein. For example, an asthma-associated parameter can be measured on day 1, day 2, day 3, day 4, day 5, day 6, day 7, day 8, day 9, day 10, day 11, day 12, day 14, or at week 3, week 4, week 5, week 6, week 7, week 8, week 9, week 10, week 11, week 12, week 13, week 14, week 15, week 16, week 17, week 18, week 19, week 20, week 21, week 22, week 23, week 24 or longer after primary treatment with the pharmaceutical composition. The difference between the parameter value at a certain time point after the start of treatment and the parameter value at baseline is used to establish whether an "improvement" of the asthma-associated parameter has occurred (e.g., increase or decrease, depending on the situation, depending on the specific parameter, measurement which is carried out).

The terms "acquire" or "acquisition" as used herein refers to taking possession of a physical object or quantity, such as a numerical value, by "direct acquisition" or "indirect acquisition" of a physical object or quantity, such as an asthma-associated parameter. "Direct acquisition" means the implementation of a method (for example, the implementation of a synthetic or analytical method) to obtain a physical object or quantity. "Indirect acquisition" refers to the receipt of a physical object or quantity from another party or source (eg, a third party laboratory that directly acquired the physical object or quantity). The direct acquisition of a physical object includes the implementation of a method that involves the physical change of a physical substance, such as a source material. Illustrative alterations include making a physical object from two or more starting materials, cutting or fragmenting a substance, separating or purifying a substance, combining two or more separate objects into a mixture, performing a chemical reaction that involves breaking or forming a covalent or non-covalent bond. Direct acquisition of a quantity includes performing a method that involves physically changing a sample or other substance, such as performing an analytical method that involves physically changing a substance, such as a sample, analyte, or reagent (sometimes referred to herein as "physical analysis").

Information acquired directly may be in the form of a report, for example, presented in paper or electronic form, such as from a database or an online application ("App"). The report or information may be provided, for example, by a healthcare facility such as a hospital or clinic; or a healthcare professional such as a doctor or nurse.

Forced expiratory volume in 1 second (FEV ₁ ). In certain embodiments, administration of an IL-4R antagonist to a patient results in an increase from baseline in forced expiratory volume in 1 second (FEV ₁ ). Methods for measuring FEV ₁ are known in the art. For example, a spirometer that complies with the 2005 American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines can be used to measure FEV ₁ in a patient. Spirometry standardization according to ATS/ERS can be used as a guide. Spirometry is typically performed between 6 am and 10 am after abstaining from albuterol for at least 6 hours. Pulmonary function tests are usually performed in the sitting position, and the highest value is recorded as FEV ₁ (in liters).

The present invention includes therapeutic methods that result in an increase in FEV ₁ from baseline by at least 0.05 L at week 12 after initiation of treatment with a pharmaceutical composition containing an IL-4R antagonist. For example, administration of an IL-4R antagonist to a subject in need causes an increase in FEV ₁ from baseline of approximately 0.05L, 0.10L, 0.12L, 0.14L, 0.16L, 0.18L, 0.20L, 0. 22L, 0.24L, 0.26L, 0.28L, 0.30L, 0.32L, 0.34L, 0.36L, 0.38L, 0.40L, 0.42L, 0.44L, 0.46L, 0.48L, 0.50L or more at week 12.

FEF25-75%. In certain embodiments, administration of an IL-4R antagonist to a patient results in an increase in FEF25-75% from baseline. Methods for measuring FEF are known in the art. For example, a spirometer that complies with the 2005 American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines can be used to measure FEV ₁ in a patient. FEF25-75 (forced expiratory flow rate 25% to 75%) is the rate (in liters per second) at which a person can release the middle half of their air during maximum exhalation (i.e. forced vital capacity or FVC). The parameter refers to the average flow from the point at which 25 percent of FVC was exhaled to the point at which 75 percent of FVC was exhaled. FEF25-75% of the subject provides information about the function of the small airways, such as the degree of disease and/or inflammation of the small airways. The change in FEF25-75 is an early indicator of obstructive pulmonary disease. In certain embodiments, the improvement and/or increase in FEF25-75% is an improvement of at least 10%, 25%, 50%, or more from baseline. In certain embodiments, the methods of the present invention result in normal FEF25-75% values in a subject (eg, values ranging from 50-60% to 130% of the mean).

Maximum expiratory flow in the morning and evening (PEF a.m. and PEF p.m.). In certain embodiments, administration of an IL-4R antagonist to a patient results in an increase from baseline in maximum morning (AM) and/or evening (PM) expiratory flow (PEF AM and/or PM PEF). Methods for measuring PEF are known in the art. For example, in one method for measuring PEF, patients are given an electronic PEF meter to record morning (am) and evening (after noon) PEF (as well as daily albuterol use, morning and evening asthma symptom scores, and number of nighttime awakenings due to asthma symptoms that require emergency medication). Patients are instructed in the use of the device and written instructions are provided to patients for the use of the electronic PEF meter. In addition, the healthcare professional may instruct patients on how to record relevant variables on the electronic PEF meter. AM PEF is usually measured within 15 minutes of getting up (6 am to 10 am) before taking any dose of albuterol. Afternoon PEF is usually taken in the evening (6 to 10 pm) before taking any dose of albuterol. Subjects should try to stop taking albuterol for at least 6 hours before measuring their PEF. The patient makes three attempts to measure PEF, and all 3 values are recorded using an electronic PEF meter. Usually, the maximum value is used for evaluation. Baseline AM PEF can be calculated as the average AM measurement recorded over 7 days prior to administration of the first dose of the pharmaceutical composition containing the IL-4R antagonist, and baseline PM PEF can be calculated as the average PM measurement recorded over 7 days prior to administration of the first dose of a pharmaceutical composition containing an IL-4R antagonist.

The present invention includes therapeutic methods that result in an increase in PEF before noon and/or PEF in the afternoon from baseline by at least 1.0 L/min. week 12 after the start of treatment with a pharmaceutical composition containing an IL-4R antagonist. For example, according to the present invention, administration of an IL-4R antagonist to a subject in need of it causes an increase in PEF from baseline by approximately 0.5 L/min, 1.0 L/min, 1.5 L/min, 2.0 L /min, 2.5L/min, 3.0L/min, 3.5L/min, 4.0L/min, 4.5L/min, 5.0L/min ., 5.5 l/min., 6.0 l/min., 6.5 l/min., 7.0 l/min., 7.5 l/min., 8.0 l/min., 8.5 L/min, 9.0 L/min, 9.5 L/min, 10.0 L/min, 10.5 L/min, 11.0 L/min, 12, 0 l/min, 15 l/min, 20 l/min or more in week 12.

Use of albuterol/levalbuterol. In certain embodiments, administration of an IL-4R antagonist to a patient results in a decrease from baseline in daily albuterol or levalbuterol use. The number of albuterol/levalbuterol inhalations may be recorded by patients daily in a diary, PEF meter, or other recording device. During treatment with the pharmaceutical composition described herein, the use of albuterol/levalbuterol, as a rule, can be carried out as needed depending on the symptoms, and not on an ongoing basis or prophylactically. The initial number of albuterol/levalbuterol inhalations per day can be calculated based on the average over the 7 days prior to the first dose of a pharmaceutical composition containing an IL-4R antagonist.

The present invention includes therapeutic methods that result in a decrease in the use of albuterol/levalbuterol from baseline by at least 0.25 injections per day at week 12 after the start of treatment with a pharmaceutical composition containing an IL-4R antagonist. For example, administration of an IL-4R antagonist to a subject in need causes a decrease in albuterol/levalbuterol use from baseline by approximately 0.25 puffs per day, 0.50 puffs per day, 0.75 puffs per day, 1.00 puffs per day, 1.25 sprays/day, 1.5 sprays/day, 1.75 sprays/day, 2.00 sprays/day, 2.25 sprays/day, 2.5 sprays/day, 2.75 sprays/day, 3 .00 injections per day or more in week 12.

Application of OCS. In certain embodiments, administration of an IL-4R antagonist to a patient may be used in combination with an OCS, such as oral prednisone. The number of OCS administrations may be recorded daily by patients in a diary, PEF meter, or other recording device. During treatment with the pharmaceutical composition described herein, intermittent short-term use of prednisone can generally be used to control acute episodes of asthma, eg, episodes in which bronchodilators and other anti-inflammatory agents fail to control symptoms. In other aspects, prednisone is used in parallel with another ICS or as a substitute for another ICS. Oral prednisone may be administered at doses of approximately 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, or 40 mg. The OCS may optionally be administered once a day or multiple times a day (e.g., twice a day, three times a day, four times a day, etc.)

In certain exemplary embodiments, the present invention provides methods for reducing or eliminating a subject's dependence on the use of OCS. Reducing or eliminating dependence on steroids is very advantageous and necessary. In certain embodiments, a reduction of 50% or more (e.g., 50%, 60%, 70%, 80%, 90% or more) of the dose of OCS is achieved after administration of an anti-IL-4R antibody therapy for a specified period of time ( e.g. week 24). In certain embodiments, OCS is substantially eliminated at 40 weeks, 45 weeks, 50 weeks, 52 weeks or more after the first dose following the loading dose. In other embodiments, the level of OCS use is reduced to less than 5 mg per day (eg, less than 5 mg, 4 mg, 3 mg, 2 mg, or less per day). In other embodiments, OCS dependence is substantially eliminated at 3 months, 6 months, 9 months, or 1 year after treatment with an anti-IL4R antibody or fragment thereof.

Score according to the 5-item Asthma Control Questionnaire (ACQ). In certain embodiments, administration of an IL-4R antagonist to a patient results in a decrease from baseline in a five-item Asthma Control Questionnaire (ACQ5). ACQ5 is an approved asthma control questionnaire.

The present invention includes therapeutic methods that result in a decrease in ACQ5 from baseline by at least 0.10 points at week 12 after initiation of treatment with a pharmaceutical composition containing an IL-4R antagonist. For example, administration of an IL-4R antagonist to a subject in need causes a reduction in ACQ from baseline of approximately 0.10 points, 0.15 points, 0.20 points, 0.25 points, 0.30 points, 0.35 points, 0.40 points, 0.45 points, 0.50 points, 0.55 points, 0.60 points, 0.65 points, 0.70 points, 0.75 points, 0.80 points, 0.85 points or more in week 12.

Awakenings at night. In certain embodiments, administration of an IL-4R antagonist to a patient results in a decrease from baseline in the average number of awakenings during the night.

In certain embodiments, the methods provide for a decrease in the average number of nighttime awakenings from baseline by at least about 0.10 times per night at week 12 after the start of treatment. For example, administration of an IL-4R antagonist to a subject in need may cause a decrease in the average number of nighttime awakenings from baseline by about 0.10 times per night, 0.15 times per night, 0.20 times per night, 0.25 times per night, 0.30 times per night, 0.35 times per night, 0.40 times per night, 0.45 times per night, 0.50 times per night, 0.55 times per night, 0.60 times per night night, 0.65 times per night, 0.70 times per night, 0.75 times per night, 0.80 times per night, 0.85 times per night, 0.90 times per night, 0.95 times per night , 1.0 times per night, 2.0 times per night or more in week 12.

22 Item Nose and Sinus Outcome Test Score (SNOT-22). In certain embodiments, administration of an IL-4R antagonist to a patient results in a decrease from baseline in a 22-item nasal and sinus disease outcome test (SNOT-22). SNOT-22 is a validated questionnaire to measure the impact of chronic rhinosinusitis on quality of life (Hopkins et al. 2009, Clin. Otolaryngol. 34: 447-454).

The present invention includes therapeutic methods that result in a decrease in SNOT-22 score from baseline by at least 1 point at week 12 after initiation of treatment with a pharmaceutical composition containing an IL-4R antagonist. For example, administration of an IL-4R antagonist to a subject in need may cause a decrease in SNOT-22 score from baseline by approximately 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 points, or more in week 12.

Biomarkers. In certain embodiments, the subject has an improvement in lung function as measured by a biomarker, such as a biomarker associated with severe steroid-dependent asthma or severe uncontrolled asthma. For example, the biomarker can be the fraction of nitric oxide in exhaled air (FeNO), eotaxin-3, total IgE, periostin, or thymus-activated chemokine (TARC). In certain embodiments, improvement in lung function is indicated by a decrease or increase (as the case may be) at week 4, week 12, or week 24 post-treatment.

Ways to treat asthma

In some embodiments, the present invention provides methods for treating asthma, including, for example, moderate to severe uncontrolled asthma or insufficiently controlled asthma, in a subject in need thereof, wherein the methods comprise administering to the subject a pharmaceutical composition comprising an IL- 4R. In certain embodiments, the methods are useful for treating moderate to severe uncontrolled asthma in a subject.

As used herein, the term "asthma" can be used interchangeably with "recurrent asthma" or "bronchial asthma". "Asthma", "bronchial asthma", and "recurrent asthma" refer to asthma for which one or any combination of the following is true: symptoms occur on or less than 2 days per week; symptoms do not interfere with daily activities; symptoms at night appear less than 2 days a month; or one or more lung function tests (eg, forced expiratory volume in one second (FEV ₁ ) and/or maximum expiratory flow (PEF) greater than 80%) are normal when the subject is not suffering from an asthma attack.

As used herein, the term "persistent asthma" or "persistent asthma" refers to asthma that is more severe than (bronchial) asthma/recurrent (bronchial) asthma. A subject suffering from persistent asthma or persistent bronchial asthma has one or more of the following: symptoms more than 2 days per week; symptoms that do not interfere with daily activities; nighttime symptoms that appear more than 2 days a month; or one or more lung function tests (eg, forced expiratory volume in one second (FEV ₁ ) and/or maximum expiratory flow (PEF) less than 80%) that are not normal when the subject is not suffering from asthma attacks; the subject is dependent on daily use of an asthma control medication; the subject has taken a systemic steroid more than once in the last year after a severe asthma attack or use of a short-acting beta-2 agonist more than two days per week to relieve asthma symptoms.

Asthma/recurrent asthma, asthma/recurrent asthma, and persistent asthma/persistent asthma may be classified as "mild", "moderate", "severe", or "moderate to severe". "Mild recurrent asthma" or "mild recurrent asthma" is defined as having symptoms less than once a week and a forced expiratory volume in one second (FEV ₁ ) or maximum expiratory flow (PEF) ≥ 80%. "Mild persistent asthma" or "mild persistent asthma" is characterized in that the frequency of symptoms is more than once a week, but less than once a day, and the variability of FEV ₁ or PEF is < 20% - 30%. "Mild recurrent asthma" or "moderate recurrent asthma" is defined as having symptoms less than once a week and a forced expiratory volume in one second (FEV ₁ ) or maximum expiratory flow (PEF) of 60-80%. "Mild persistent asthma" or "moderate persistent asthma" is defined as the presence of daily symptoms, exacerbations that may affect activity and/or sleep, nocturnal symptoms more than once a week, daily use of a short-acting inhaled beta-2-agonist, and volume forced expiration in one second (FEV ₁ ) or maximum expiratory flow (PEF) at the level of 60-80%. "Severe recurrent asthma" or "severe recurrent asthma" is defined as having symptoms less than once a week and having a forced expiratory volume in one second (FEV ₁ ) or a maximum expiratory flow (PEF) of 60%. "Severe persistent asthma" or "severe persistent asthma" is defined as the presence of daily symptoms, frequent exacerbations that may affect activity and/or sleep, frequent nocturnal symptoms, limitation of physical activity, daily use of a short-acting inhaled beta-2-agonist, and forced expiratory volume in one second (FEV ₁ ) or maximum expiratory flow (PEF) at 60%. "Moderate to severe recurrent asthma" or "moderate to severe recurrent asthma" is defined as the presence of symptoms between those of moderate recurrent asthma/moderate recurrent asthma and severe recurrent asthma/severe recurrent asthma. "Moderate to severe persistent asthma" or "moderate to severe persistent asthma" is defined as the presence of symptoms between those of moderate persistent asthma/moderate persistent asthma and severe persistent asthma/severe persistent asthma.

As used herein, the term "under-controlled asthma" refers to patients whose asthma is either "not well controlled" or "very poorly controlled" as defined in Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. ," National Heart, Blood and Lung Institute, NIH, Aug. 28, 2007. "Not well controlled asthma" is defined as having symptoms for more than two days a week, nighttime awakenings one to three times a week, some restrictions on daily activities, use of a short-acting _beta2- agonist to control symptoms for more than two once a week, FEV ₁ at 60-80% of predicted value and/or personal best, ATAQ score of 1-2, ACQ score of 1.5 or more, and ACT score of 16-19. "Very poorly controlled asthma" is defined as having symptoms during the day, waking at night four times or more per week, significant restrictions on daily activities, use of a short-acting _beta2- agonist to control symptoms several times a day, FEV ₁ less than 60% predicted value and/or personal best, an ATAQ score of 3-4, no ACQ score data, and an ACT score of 15 or less.

In some embodiments, a subject is defined as having "moderate to severe uncontrolled asthma" if the subject receives such a diagnosis from a physician based on the 2009 Global Initiative on Asthma (GINA) guidelines and one or more of the following criteria: i) current treatment moderate to high doses of ICS/LABA (2 doses of fluticasone propionate 250 mcg twice daily or an equivalent daily dose of ICS) with a stable dose of ICS/LABA for a period of 1 month or more prior to administration of a loading dose of an IL-4R antagonist; ii) FEV ₁ constituting 40-80% of the predicted norm prior to the introduction of a loading dose of an antagonist IL-4R; iii) an ACQ-5 score of 1.5 or greater prior to administration of a loading dose of an IL-4R antagonist; iv) at least 12% reversibility and 200 ml FEV ₁ after 200-400 μg (2-4 inhalations) of salbutamol/albuterol prior to administration of a loading dose of an IL-4R antagonist; or v) any of the following events occurred within 1 year prior to administration of an IL-4R antagonist loading dose: (a) treatment with 1 or more systemic pulsed steroids (oral or parenteral) for an asthma exacerbation, (b) hospitalization, or A visit to the emergency/accident department due to an asthma exacerbation.

The expression "severe asthma" refers to asthma in which adequate control cannot be achieved by treatment with high doses of inhaled corticosteroids and additional controller drugs (eg, long-acting inhaled beta2-agonists, montelukast, and/or theophylline) or oral corticosteroid therapy (eg. , for at least six months of the year), or is lost when treatment is reduced. In certain embodiments, severe asthma includes asthma treated with high doses of ICS and at least one additional controller drug (e.g., LABA, montelukast, or theophylline) or oral corticosteroids > 6 months/year, where at least one of the following occurs or may occur if treatment is reduced: ACT < 20 or ACQ > 1.5; at least 2 exacerbations in the last 12 months; at least 1 exacerbation treated in a hospital or requiring mechanical ventilation in the last 12 months; or FEV1<80% (if FEV1/FVC is below the lower limit of normal).

The expression "steroid-dependent asthma" refers to asthma that requires one or more of the following treatments: treatment with frequent short-term pulse therapy with oral corticosteroids within the last 12 months; regular use of high doses of inhaled corticosteroids during the last 12 months; regular use of long-acting injectable corticosteroids; daily use of oral corticosteroids; oral corticosteroids every other day or long-term use of oral corticosteroids in the past year.

The term "oral corticosteroid-dependent asthma" refers to a subject having ≥ 3 30-day courses of oral corticosteroid (OCS) over a 12-month period and a primary diagnosis of asthma within 12 months of the first course of OCS. Subjects with OCS-related asthma may also have one or any combination of the following: have received physician-prescribed LABAs and a high dose of ICS (total daily dose > 500 mcg of fluticasone propionate dry powder formulation equivalent) for at least 3 months (ICS and LABA may be part of a combination product or provided in separate inhalers); received additional maintenance asthma-control medications in accordance with standard treatment practice, eg, leukotriene receptor antagonists (LTRA), theophylline, long-acting muscarinic receptor antagonists (LAMA), secondary ICS, and cromones; received OCS for asthma at a dose of ≥ 7.5 to ≤ 30 mg (prednisone or prednisolone equivalent); received a dose of OCS administered every other day (or different doses every other day); FEV1 in the morning before bronchodilator (BD) administration is < 80% predicted; the presence of asthma signs, confirmed by the reversibility of FEV1 ≥ 12% and ≥ 200 ml after BD (albuterol / salbutamol) (15-30 minutes after administration of 4 injections of albuterol / salbutamol); or have a history of at least one asthma exacerbation within 12 months.

In one aspect, methods for treating asthma are provided comprising (a) selecting a patient that has a blood eosinophil count of at least 300 cells per microliter; and (b) administering to the patient a pharmaceutical composition containing an IL-4R antagonist.

In another aspect, methods for treating asthma are provided comprising (a) selecting a patient who has a blood eosinophil count of 200-299 cells per microliter; and (b) administering to the patient a pharmaceutical composition containing an IL-4R antagonist.

In another aspect, methods for treating asthma are provided comprising (a) selecting a patient who has a blood eosinophil count of less than 200 cells per microliter; and (b) administering to the patient a pharmaceutical composition containing an IL-4R antagonist.

In a related aspect, methods for treating asthma are provided that provide additional therapy to background therapy. In certain embodiments, the IL-4R antagonist is administered as add-on therapy to an asthma patient who is on background therapy for a specified period of time (e.g., 1 week, 2 weeks, 3 weeks, 1 month, 2 months, 5 months, 12 months, 18 months, 24 months or longer) (also called "stable phase"). In some embodiments, the background therapy includes ICS and/or LABA.

In some embodiments, the present invention includes a method of reducing a patient with asthma's dependence on ICS and/or LABA to treat one or more asthma exacerbations, comprising (a) selecting a patient who has moderate to severe asthma that is not controlled by background asthma therapy providing for ICS, LABA, or a combination thereof; and administering to the patient a pharmaceutical composition containing the IL-4R antagonist.

In some embodiments, the present invention encompasses methods of treating or alleviating conditions or complications associated with asthma, such as chronic rhinosinusitis, allergic rhinitis, allergic fungal rhinosinusitis, allergic bronchopulmonary aspergillosis, combined airways disease, Churg-Strauss syndrome, vasculitis, chronic obstructive disease lungs (COPD) and exercise-induced bronchospasm.

The present invention also includes methods for the treatment of persistent asthma. As used herein, the term "persistent asthma" means that the subject has symptoms at least once a week during the day and/or night, with the symptoms lasting from several hours to several days. In certain alternative embodiments, persistent asthma is "mildly persistent" (e.g., more than twice a week but less than once a day with symptoms that are severe enough to interfere with activities of daily living or sleep and/or if respiratory function is normal or reversible with inhaled bronchodilator), "moderately persistent" (eg, symptoms occur daily, with sleep interrupted at least once a week and/or respiratory function is moderately impaired), or "severely persistent" (eg, continuous symptoms, despite correct use of approved medicinal products and/or if respiratory function is severely impaired).

Interleukin-4 receptor antagonists

The methods of the present invention involve administering to a subject in need thereof a therapeutic composition comprising an IL-4R antagonist. As used herein, the term "IL-4R antagonist" means any agent that binds to or interacts with human IL-4R and inhibits normal IL-4R biological signaling when IL-4R is expressed on a cell in vitro or in vivo. Non-limiting examples of IL-4R antagonist categories include small molecule IL-4R antagonists, IL-4R aptamers, IL-4R peptide antagonists (e.g., "peptide-associated antibody" molecules), and antibodies or antigen-binding antibody fragments that specifically bind to Human IL-4R. In certain embodiments, the IL-4R antagonist provides an anti-IL-4R antibody that can be used in the context of the methods provided herein as described elsewhere herein. For example, in one embodiment, an IL-4R antagonist is an antibody or antigen-binding fragment thereof that specifically binds to IL-4R and contains the heavy chain and light chain CDR (complementarity determining region) sequences from the heavy chain variable region (HCVR) and the light chain variable region. chains (LCVR) under SEQ ID NO:1 and 2, respectively.

The term "human IL4R" (hIL-4R) refers to a human cytokine receptor that specifically binds to interleukin-4 (IL-4), such as IL-4Rα.

The term "antibody" refers to immunoglobulin molecules containing four polypeptide chains, two heavy (H) chains and two light (L) chains linked by disulfide bonds, as well as their multimers (eg, IgM). Each heavy chain contains a heavy chain variable region (abbreviated herein as HCVR or V _H ) and a heavy chain constant region. The heavy chain constant region contains three domains: C _H 1 , C _H 2 and C _H 3. Each light chain contains a light chain variable region (abbreviated herein as LCVR or V _L ) and a light chain constant region. The constant region of the light chain contains one domain (C _L 1). The V _H and V _L regions can be further subdivided into regions of hypervariability called complementarity determining regions (CDRs) interspersed with more conserved regions called framework regions (FRs). Each V _H and V _L consists of three CDRs and four FRs, arranged from amino to carboxy in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In various embodiments, the FR of an anti-IL-4R antibody (or antigen-binding site thereof) may be identical to human germline immunoglobulin sequences, or may be naturally or artificially modified. The amino acid consensus sequence can be determined based on a side-by-side analysis of two or more CDRs.

The term "antibody" also includes antigen-binding fragments of whole antibody molecules. The terms "antigen-binding site" of an antibody, "antigen-binding fragment" of an antibody, and the like, as used herein, include any naturally occurring, enzymatically produced, synthetic, or genetically engineered polypeptide or glycoprotein that specifically binds to an antigen to form a complex . Antigen-binding fragments of an antibody can be obtained, for example, from whole antibody molecules using any suitable standard techniques, such as proteolytic cleavage or recombinant genetic engineering techniques, including the manipulation of DNA encoding the variable and optionally constant domains of the antibody, and its expression. Such DNA is known and/or readily available, for example from commercial sources, DNA libraries (including, for example, phage-antibody libraries), or can be synthesized. DNA can be sequenced and chemically manipulated or manipulated using molecular biology techniques, for example, to arrange one or more variable and/or constant domains in a suitable configuration, or to introduce codons, create cysteine residues, modify, add or remove amino acids, and etc.

Non-limiting examples of antigen-binding fragments include (i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single chain Fv molecules (scFv); (vi) dAb fragments; and (vii) minimal recognition units consisting of amino acid residues that mimic an antibody hypervariable region (e.g., a distinct complementarity determining region (CDR) such as a CDR3 peptide) or a conformationalally restricted FR3-CDR3 peptide -FR4. Other engineered molecules such as domain-specific antibodies, single-domain antibodies, domain-deleted antibodies, chimeric antibodies, CDR-grafted antibodies, diabodies, tribodies, tetrabodies, minibodies, nanobodies (e.g., monovalent antibodies, bivalent antibodies, etc.) , small modular protein (SMIP) immunopharmaceuticals, and shark IgNAR variable domains are also included in the expression "antigen binding fragment".

An antigen binding fragment of an antibody will typically contain at least one variable domain. The variable domain may be of any size or amino acid composition and will typically contain at least one CDR that is adjacent to or in-frame with one or more framework sequences. In antigen-binding fragments having a V _H domain linked to a V _L domain, the V _H and V _L domains can be arranged relative to each other in any suitable order. For example, the variable region may be dimeric and contain V _H -V _H , V _H -V _L or V _L -V _L dimers. Alternatively, the antigen-binding fragment of an antibody may comprise a V _H or V _L monomeric domain.

In certain embodiments, an antigen-binding fragment of an antibody may comprise at least one variable domain covalently linked to at least one constant domain. Non-limiting exemplary variable and constant domain configurations that can be detected in an antigen-binding fragment of an antibody described herein include (i) V _{H -CH} 1; (ii) V _H -C _H 2; (iii) V _H -C _H 3; (iv) V _H -C _H 1 -C _H 2; (v) V _H -C _H 1 -C _H 2 -C _H 3; (vi) V _H -C _H 2 -C _H 3; (vii) V _H -C _L ; (viii) V _L -C _H 1; (ix) V _{L -CH} 2; (x) V _L -C _H 3; (xi) V _L -C _H 1 -C _H 2; (xii) V _L -C _H 1 -C _H 2 -C _H 3; (xiii) V _L -C _H 2 -C _H 3 and (xiv) V _L -C _L . In any configuration of the variable and constant domains, including any of the exemplary configurations listed above, the variable and constant domains may either be directly linked to each other or may be linked through an entire or partial hinge or linker region. The hinge region may be composed of at least 2 (e.g., 5, 10, 15, 20, 40, 60 or more) amino acids, which result in the formation of a flexible or semi-flexible bond between adjacent variable and/or constant domains in a single polypeptide molecule. typically, the hinge region may be 2-60 amino acids, typically 5-50 or typically 10-40 amino acids. In addition, the antigen-binding fragment of an antibody described herein may comprise a homodimer or heterodimer (or other multimer) of any of the variable and constant domain configurations set forth above in non-covalent association with each other and/or with one or more V _H monomeric domains. or V _L (eg via disulfide bond(s)).

As with whole antibody molecules, antigen binding fragments can be monospecific or multispecific (eg, bispecific). A multispecific antigen-binding fragment of an antibody will typically contain at least two distinct variable domains, where each variable domain is capable of specifically binding to a separate antigen or to a different epitope on the same antigen. Any multispecific antibody format can be adapted for use in the context of the antigen-binding antibody fragment described herein using standard techniques available in the art.

The constant region of an antibody is important in terms of the ability of the antibody to bind complement and mediate cell-dependent cytotoxicity. Thus, the antibody isotype can be selected based on whether the antibody is required to mediate cytotoxicity.

The term "human antibody" includes antibodies having variable and constant regions derived from human germline immunoglobulin sequences. The human antibodies provided herein may include amino acid residues not encoded by human germline immunoglobulin sequences (e.g., mutations introduced by in vitro random or site-specific mutagenesis or in vivo somatic mutation), for example, in CDRs and, in in particular, CDR3. However, the term "human antibody" does not include antibodies in which CDR sequences derived from the germline of another mammalian species, such as a mouse, are grafted onto human framework sequences.

The term "recombinant human antibody" includes all human antibodies produced, expressed, generated or isolated by recombinant techniques, such as antibodies expressed using a recombinant expression vector transfected into a host cell (described further below), antibodies isolated from a combinatorial library of recombinant human antibodies (described further below), antibodies isolated from an animal (e.g., mouse) that is transgenic for human immunoglobulin genes (see, e.g., Taylor et al. (1992) Nucl. Acids Res. 20:6287-6295) , or antibodies produced, expressed, generated or isolated by any other means that involve splicing human immunoglobulin gene sequences with other DNA sequences. Such recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences. However, in certain embodiments, such recombinant human antibodies are subjected to in vitro mutagenesis (or, in the case of an animal transgenic for human Ig sequences, somatic mutagenesis in vivo) and thus the amino acid sequences of the V _H and V _L regions of the recombinant antibodies are sequences which, while derived from and related to human germline V _H and V _L sequences, may not occur naturally in the in vivo human germline antibody repertoire.

Human antibodies can occur in two forms due to the heterogeneity of the hinge regions. In one form, the immunoglobulin molecule contains a stable four-chain construct of about 150-160 kDa in which the dimers are held together by an interchain disulfide bond that links the heavy chains. In the second form, the dimers are not connected by interchain disulfide bonds, and a molecule of approximately 75-80 kDa is formed, consisting of covalently linked light and heavy chains (half-antibody). These forms are extremely difficult to separate even after affine purification.

The frequency of appearance of the second form in different isotypes of intact IgG is due, without limitation, to structural differences associated with the isotype of the hinge region of the antibody. A single amino acid substitution at the human IgG4 hinge can significantly reduce the appearance of the second form (Angal et al. (1993) Molecular Immunology 30:105) to levels normally seen with a human IgG1 hinge. The present invention encompasses antibodies with one or more mutations in the hinge, C _H 2 or C _H 3 region, which may be preferred, eg under production conditions, to increase the yield of the preferred antibody form.

The term "isolated antibody" means an antibody that has been identified and isolated and/or recovered from at least one component of its natural environment. For example, an antibody that has been isolated or removed from at least one component of an organism, or from a tissue or cell in which the antibody is originally present or naturally produced, is an "isolated antibody". An isolated antibody also includes an antibody in situ in a recombinant cell. Isolated antibodies are antibodies that have been subjected to at least one purification or isolation step. In certain embodiments, the isolated antibody may be substantially free of other cellular material and/or other chemical compounds.

The term "specifically binds" and the like. means that the antibody or antigen-binding fragment forms a complex with an antigen that is relatively stable under physiological conditions. Methods for determining the presence of specific binding of an antibody to an antigen are well known in the art and include, for example, equilibrium dialysis, surface plasmon resonance, and the like. For example, an antibody that "specifically binds" to IL-4R as provided herein includes antibodies that bind to IL-4R, or a portion thereof, with a K _D of less than about 1000 nM, less than about 500 nM, less than about 300 nM, less than about 200 nM, less than about 100 nM, less than about 90 nM, less than about 80 nM, less than about 70 nM, less than about 60 nM, less than about 50 nM, less than about 40 nM, less than about 30 nM, less than about 20 nM, less than about 10 nM, less than about 5 nM, less than about 4 nM, less than about 3 nM, less than about 2 nM, less than about 1 nM, or less than about 0.5 nM as measured in a surface plasmon resonance assay. However, an isolated antibody that specifically binds to human IL-4R is cross-reactive with other antigens, such as IL-4R molecules from other (non-human) species.

Anti-IL-4R antibodies useful in the methods of the present invention may contain one or more amino acid substitutions, insertions, and/or deletions (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 substitutions and /or 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 inserts and/or 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 substitutions) in the frame sections and /or regions of the CDRs of the variable domains of the heavy and light chains compared to the corresponding germline sequences from which the antibodies were derived. Such mutations can be readily identified by comparing the amino acid sequences disclosed herein with germline sequences available, for example, from public antibody sequence databases. The present invention includes methods involving the use of antibodies and antigen-binding fragments thereof, which are derived from any of the amino acid sequences disclosed herein, where one or more amino acids (for example, 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 amino acids) in one or more framework regions and/or one or more (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 relative to a tetrameric antibody, or 1, 2, 3, 4, 5, or 6 with respect to the HCVR and LCVR antibodies) the CDR regions are mutated into the corresponding germline sequence residue(s) from which the antibody is derived, or into the corresponding sequence residue(s) of another human germline sequence, or to a conservative amino acid substitution of the appropriate germline residue(s) (such sequence changes are collectively referred to herein as "germline mutations"). One of skill in the art, starting from the heavy and light chain variable region sequences disclosed herein, can easily generate a variety of antibodies and antigen-binding fragments that contain one or more individual germline mutations, or combinations thereof. In certain embodiments, all framework and/or CDR residues in the V _H and/or V _L domains are back-mutated to result in residues occurring in the original germline sequence from which the antibody was derived. In other embodiments, only certain residues are mutated back into the original germline sequence, for example, only mutated residues found in the first 8 amino acids of FR1 or the last 8 amino acids of FR4, or only mutated residues found in CDR1, CDR2, or CDR3. In other embodiments, one or more framework and/or CDR residues are mutated into the corresponding residue(s) of a different germline sequence (i.e., a germline sequence that differs from the germline sequence from which the antibody was originally derived). In addition, antibodies may contain any combination of two or more germline mutations in the framework regions and/or CDR regions, for example, where certain individual residues are mutated into the corresponding residue of the specified germline sequence, while certain other residues that differ from the sequence of the original germline, are retained or mutated into the corresponding residue of the sequence of another germline. Once produced, antibodies and antigen-binding fragments that contain one or more germline mutations can be readily tested for one or more preferred properties such as improved binding specificity, increased binding affinity, improved or enhanced biological antagonist or agonist properties (in depending on the situation), reduced immunogenicity, etc. The use of antibodies and antigen-binding fragments obtained using this General method, covered in the present invention.

The present invention also includes methods involving the use of antibodies to IL-4R containing variants of any of the HCVR, LCVR and/or CDR amino acid sequences disclosed herein, with one or more conservative substitutions. For example, the present invention includes the use of antibodies to IL-4R with the amino acid sequences of HCVR, LCVR, and/or CDR, for example, 10 or less, 8 or less, 6 or less, 4 or less, and the like. conservative amino acid substitutions with respect to any of the HCVR, LCVR and/or CDR amino acid sequences disclosed herein.

The term "surface plasmon resonance" refers to an optical phenomenon that provides real-time analysis of interactions by detecting changes in protein concentrations in a biosensor array, for example, using the BIAcore™ system (a division of Biacore Life Sciences at GE Healthcare, Piscataway, New Jersey).

The term "K _D " refers to the equilibrium dissociation constant of the interaction of a particular antibody and antigen.

The term "epitope" refers to an antigenic determinant that interacts with a specific antigen-binding site in the variable region of an antibody molecule known as a paratope. One antigen may have more than one epitope. Thus, different antibodies can bind to different regions on an antigen and can have different biological effects. Epitopes may be conformational or linear. A conformational epitope is formed by spatially contiguous amino acids from different segments of a linear polypeptide chain. A linear epitope is formed by adjacent amino acid residues in a polypeptide chain. Under certain conditions, the epitope may include fragments of saccharides, phosphoryl groups or sulfonyl groups of the antigen.

Obtaining human antibodies

Methods for producing human antibodies in transgenic mice are known in the art. Any such known methods can be used to generate human antibodies that specifically bind to human IL-4R.

Using VELOCIMMUNE® technology (see, for example, US 6596541, Regeneron Pharmaceuticals) or any other known method for producing monoclonal antibodies, high affinity chimeric antibodies to IL-4R with a human variable region and a mouse constant region are initially isolated. The VELOCIMMUNE® technology involves generating a transgenic mouse with a genome containing human heavy and light chain variable regions operably linked to endogenous mouse constant region loci such that the mouse produces an antibody containing the human variable region and the mouse constant region in response to antigen challenge. DNA encoding the variable regions of the heavy and light chains of an antibody is isolated and operably linked to DNA encoding the constant regions of the human heavy and light chains. The DNA is then expressed in a cell capable of expressing a fully human antibody.

Typically, a VELOCIMMUNE®-derived mouse is exposed to an antigen of interest and lymphatic cells (such as B cells) are recovered from mice that express antibodies. Lymph cells can be fused with a myeloma cell line to form immortalized hybridoma cell lines, and such hybridoma cell lines are screened and selected to identify hybridoma cell lines that produce antibodies specific for the antigen of interest. DNA encoding the heavy chain and light chain variable regions can be isolated and linked to the constant regions of the desired heavy chain and light chain isotypes. Such an antibody protein can be produced in a cell, such as a CHO cell. Alternatively, DNA encoding antigen-specific chimeric antibodies or light and heavy chain variable domains can be isolated directly from antigen-specific lymphocytes.

Initially, high-affinity chimeric antibodies with a human variable region and a mouse constant region are isolated. Antibodies are characterized and selected for preferred characteristics, including affinity, selectivity, epitope, etc., using standard procedures known to those skilled in the art. Mouse constant regions are replaced with the desired human constant region to produce a fully human antibody of the present invention, eg, wild-type IgG1 or IgG4 or modified IgG1 or IgG. While the constant region chosen may vary depending on the particular application, the variable region retains the characteristics of high affinity antigen binding and target specificity.

Typically, antibodies that can be used in the methods have high affinity, as described above, when measuring antigen binding, both when immobilized on the solid phase and in the liquid phase. Mouse constant regions are replaced with the desired human constant regions to produce fully human antibodies of the present invention. While the constant region chosen may vary depending on the particular application, the variable region retains the characteristics of high affinity antigen binding and target specificity.

In one embodiment, a human antibody or antigen-binding fragment thereof that specifically binds to IL-4R that can be used in the context of the methods of the present invention contains three heavy chain CDRs (HCDR1, HCDR2 and HCDR3) contained in the heavy chain variable region (HCVR) with the amino acid sequence of SEQ ID NO: 1. The antibody or antigen-binding fragment may contain three light chain CDRs (LCVR1, LCVR2, LCVR3) contained in the light chain variable region (LCVR) with the amino acid sequence of SEQ ID NO: 2. Methods and techniques for identifying CDRs in HCVR and LCVR amino acid sequences are well known in the art and can be used to identify CDRs in certain HCVR and/or LCVR amino acid sequences disclosed herein. Illustrative conventional methods that can be used to identify CDR boundaries include, for example, Kabat detection, Chothia detection, and AbM detection. In general, the Kabat definition is based on sequence variability, the Chothia definition is based on the position of structural loop regions, and the AbM definition is a compromise between the Kabat and Chothia approaches. See, for example, "Kabat, Sequences of Proteins of Immunological Interest", National Institutes of Health, Bethesda, Md. (1991); Al-Lazikani et al., J. Mol. Biol. 273:927-948 (1997); and Martin et al., Proc. Natl. Acad. sci. USA 86:9268-9272 (1989). Public databases are also available for identifying CDR sequences in an antibody.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) of heavy and light chain variable region (HCVR/LCVR) amino acid sequence pairs under SEQ ID NOS: 1 and 2.

In certain embodiments, the antibody or antigen-binding fragment thereof contains six CDRs (HCDR1/HCDR2/HCDR3/LCDR1/LCDR2/LCDR3) with amino acid sequences under SEQ ID NO: 3/4/5/6/7/8.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises the HCVR/LCVR amino acid sequence pairs of SEQ ID NOS: 1 and 2.

In one embodiment, the antibody is dupilumab which contains the HCVR/LCVR amino acid sequence pairs of SEQ ID NOS: 1 and 2.

Pharmaceutical compositions

The present invention includes methods that involve administering an IL-4R antagonist to a patient, wherein the IL-4R antagonist is contained in a pharmaceutical composition. Pharmaceutical compositions of the present invention are formulated with suitable carriers, adjuvants, and other means that provide suitable transfer, delivery, tolerability, and the like. Many suitable formulations can be found in the reference book known to all pharmaceutical chemists: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. These formulations include, for example, powders, pastes, ointments, jellies, waxes, oils, lipids, vesicles containing (cationic or anionic) lipids (such as LIPOFECTIN™), DNA conjugates, anhydrous absorption pastes, oil-in-water emulsions and water-in-oil, carbovax emulsions (polyethylene glycols of various molecular weights), semi-liquid gels and semi-liquid mixtures containing carbovax. See also Powell et al. "Compendium of excipients for parenteral formulations" PDA (1998) J Pharm Sci Technol 52:238-311.

The dose of antibody administered to a patient may vary depending on the patient's age and size, symptoms, conditions, route of administration, and the like. The dose is usually calculated according to body weight or body surface area. Depending on the severity of the condition, the frequency and duration of treatment can be adjusted. Effective dosages and administration schedules for pharmaceutical compositions containing anti-IL-4R antibodies can be empirically determined; for example, the progress of the patient's condition can be monitored by periodic evaluation and the dose adjusted accordingly. In addition, cross-species dosage calculations can be performed using methods well known in the art (eg, Mordenti et al., 1991, Pharmaceut. Res. 8:1351).

Various delivery systems are known and can be used to administer the pharmaceutical compositions of the present invention, e.g., encapsulation in liposomes, microparticles, microcapsules, recombinant cells capable of expressing mutant viruses, receptor-mediated endocytosis (see e.g. Wu et al., 1987, J Biol Chem 262:4429-4432). Routes of administration include, without limitation, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, intratracheal, epidural, and oral routes. The composition can be administered by any convenient route, such as infusion or bolus injection, absorption through epithelial or mucocutaneous integuments (eg, oral mucosa, rectal and intestinal mucosa, etc.), and can be administered in conjunction with other biologically active agents.

The pharmaceutical composition of the present invention can be delivered subcutaneously or intravenously using a standard needle and syringe. In addition, with respect to subcutaneous delivery, when delivering the pharmaceutical composition of the present invention, a pen-type delivery device (eg, an auto-injection pen) is widely used. Such a delivery device in the form of a pen can be reusable and disposable. A refillable pen delivery device typically uses a replaceable cartridge that contains a pharmaceutical composition. After all of the pharmaceutical composition has been administered from the cartridge, and after the cartridge has been emptied, the empty cartridge can be easily disposed of and replaced with a new cartridge that contains the pharmaceutical composition. The pen delivery device can then be reused. The disposable pen delivery device does not have a replaceable cartridge. Instead, the disposable pen delivery device is delivered pre-filled with the pharmaceutical composition contained in the device's reservoir. After the reservoir is emptied of the pharmaceutical composition, the device is completely disposed of.

Numerous reusable pen and autoinjector delivery devices are used in subcutaneous delivery of a pharmaceutical composition. Examples include, without limitation, AUTOPEN™ (Owen Mumford, Inc., Woodstock, UK), DISETRONIC™ pen (Disetronic Medical Systems, Burgdorf, Switzerland), HUMALOG MIX 75/25™ pen, HUMALOG™ pen, syringe - HUMALIN 70/30™ pen (Eli Lilly and Co., Indianapolis, Indiana), NOVOPEN™ I, II and III (Novo Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR™ (Novo Nordisk, Copenhagen, Denmark), syringe pen BD™ (Becton Dickinson, Franklin Lakes, NJ), OPTIPEN™, OPTIPEN PRO™, OPTIPEN STARLET™ and OPTICLIK™ (Sanofi-Aventis, Frankfurt, Germany), just to name a few. Examples of reusable pen delivery devices for use in subcutaneous administration of the pharmaceutical composition of the present invention include, but are not limited to SOLOSTAR™ pen (Sanofi-Aventis), FLEXPEN™ (Novo Nordisk) and KWIKPEN™ (Eli Lilly) , SURECLICK ^TM autoinjector (Amgen, Thousand Oaks, CA), PENLET ^TM (Haselmeier, Stuttgart, Germany), EPIPEN (Dey, LP), and HUMIRA ^TM pen (Abbott Labs, Abbott Park, IL) are mentioned. just some of them. Examples of high volume delivery devices (e.g., high volume injectors) include, but are not limited to, bolus injectors such as, for example, BD Libertas West SmartDose, Enable Injections, SteadyMed PatchPump, Sensile SenseTrial, YPsomed YpsoDose, Bespak Lapas, and the like.

For direct administration to the sinuses, the pharmaceutical compositions of the present invention may be administered using, for example, a microcatheter (eg, endoscope and microcatheter), nebulizer, powder dispenser, nebulizer, or inhaler. The methods involve administering an IL-4R antagonist to a subject in need in an aerosol formulation. For example, antibodies to IL-4R in the form of an aerosol can be administered to a patient for the treatment of asthma. Aerosol antibodies can be obtained as described, for example, in US 8178098, incorporated herein by reference in its entirety.

In certain situations, the pharmaceutical composition may be delivered in a controlled release system. In one embodiment, a pump can be used (see Langer, supra; Sefton, 1987, CRC Crit. Ref. Biomed. Eng. 14:201). In another embodiment, polymeric materials can be used; see Medical Applications of Controlled Release, Langer and Wise (eds.), 1974, CRC Pres., Boca Raton, Florida. In yet another embodiment, the controlled release system can be placed near the target of the composition, requiring only a fraction of the systemic dose (see, for example, Goodson, 1984, in Medical Applications of Controlled Release, supra, vol. 2, page 115 -138). Other controlled release systems are reviewed by Langer, 1990, Science 249:1527-1533.

Injectable preparations may include dosage forms for intravenous, subcutaneous, intradermal and intramuscular injections, drip infusions, etc. These injectable preparations can be obtained using known methods. For example, injectable preparations can be prepared, for example, by dissolving, suspending or emulsifying an antibody or salt thereof, as described above, in a sterile aqueous or oily medium commonly used for injection. The aqueous injection medium is, for example, physiological saline, an isotonic solution containing glucose and other adjuvants, etc., which can be used in combination with a suitable solubilizing agent such as an alcohol (for example, ethanol), a polyhydric alcohol (for example, , propylene glycol, polyethylene glycol), a nonionic surfactant (eg, polysorbate 80, HCO-50 (polyoxyethylene (50 mol) hydrogenated castor oil adduct)) etc. As the oil medium, for example, sesame oil, soybean oil, etc. are used, which can be used in combination with a solubilizing agent such as benzyl benzoate, benzyl alcohol, etc. The injection form thus obtained is usually filled into a suitable ampoule.

Advantageously, the pharmaceutical compositions for oral or parenteral administration described above are formulated into unit dosage forms suitable for adjusting the dosage of the active ingredients. Such unit dosage forms include, for example, tablets, pills, capsules, injectables (ampoules), suppositories, and the like.

Exemplary pharmaceutical compositions containing an anti-IL-4R antibody that can be used in the present invention are disclosed, for example, in US Patent Application Publication No. 2012/0097565.

Dose

The amount of an IL-4R antagonist (eg, an anti-IL-4R antibody) administered to a subject according to the methods of the present invention is generally a therapeutically effective amount. As used herein, "therapeutically effective amount" means an amount of an IL-4R antagonist that results in one or more of the following: (a) reducing the frequency of asthma exacerbations; (b) improvement in one or more asthma-associated parameters (as defined elsewhere herein) and/or (c) detectable improvement in one or more symptoms or manifestations of an inflammatory condition of the upper respiratory tract. The term "therapeutically effective amount" also includes an amount of an IL-4R antagonist that inhibits, prevents, reduces, or delays the progression of asthma in a subject.

In the case of an anti-IL-4R antibody, a therapeutically effective amount may be from about 0.05 mg to about 700 mg, for example, about 0.05 mg, about 0.1 mg, about 1.0 mg, about 1.5 mg, about 2.0 mg, approximately 3.0 mg, approximately 5.0 mg, approximately 7.0 mg, approximately 10 mg, approximately 20 mg, approximately 30 mg, approximately 40 mg, approximately 50 mg, approximately 60 mg, approximately 70 mg , approximately 80 mg, approximately 90 mg, approximately 100 mg, approximately 110 mg, approximately 120 mg, approximately 130 mg, approximately 140 mg, approximately 150 mg, approximately 160 mg, approximately 170 mg, approximately 180 mg, approximately 190 mg, approximately 200 mg, approximately 210 mg, approximately 220 mg, approximately 230 mg, approximately 240 mg, approximately 250 mg, approximately 260 mg, approximately 270 mg, approximately 280 mg, approximately 290 mg, approximately 300 mg, approximately 310 mg, approximately 320 mg , approximately 330 mg, approximately 340 mg, approximately 350 mg, approximately 360 mg, approximately 370 mg, approximately 380 mg, approximately 390 mg, approximately 400 mg, approximately 410 mg, approximately 420 mg, approximately 430 mg, approximately 440 mg, approximately 450 mg, approximately 460 mg, approximately 470 mg, approximately 480 mg, approximately 490 mg, approximately 500 mg, approximately 510 mg, approximately 520 mg, approximately 530 mg, approximately 540 mg, approximately 550 mg, approximately 560 mg, approximately 570 mg , approximately 580 mg, approximately 590 mg, approximately 600 mg, approximately 610 mg, approximately 620 mg, approximately 630 mg, approximately 640 mg, approximately 650 mg, approximately 660 mg, approximately 670 mg, approximately 680 mg, approximately 690 mg or approximately 700 mg anti-IL-4R antibody. In certain embodiments, 300 mg of an anti-IL-4R antibody is administered.

The amount of antagonist to IL-4R, contained in individual doses, can be expressed in milligrams of antibody per kilogram of body weight of the patient (ie, mg/kg). For example, an IL-4R antagonist may be administered to a patient at a dose of about 0.0001 to about 10 mg/kg of the patient's body weight. For example, an IL-4R antagonist may be administered at a dose of 1 mg/kg, 2 mg/kg, 3 mg/kg, or 4 mg/kg.

In some embodiments, the dose of the IL-4R antagonist may vary according to the eosinophil content. For example, a subject may have a blood eosinophil count (high blood eosinophil count) of ≥ 300 cells/µl, or 300-499 cells/µl, or ≥ 500 cells/µl (HEo); the content of eosinophils in the blood, constituting 200-299 cells / μl (moderate content of eosinophils in the blood); or a blood eosinophil count of < 200 cells/mcL (low blood eosinophil count).

In certain embodiments, the methods provide for a loading dose of about 400 to about 600 mg of an IL-4R antagonist.

In certain embodiments, the methods include one or more maintenance doses of about 200 to about 300 mg of an IL-4R antagonist.

In certain embodiments, ICS and LABA are administered during the entire period of administration of the IL-4R antagonist.

In certain embodiments, the loading dose is 600 mg of the anti-IL-4R antibody or antigen-binding fragment thereof, and one or more maintenance doses are 300 mg of the antibody or antigen-binding fragment thereof administered biweekly.

In certain embodiments, the loading dose is 400 mg of the anti-IL-4R antibody or antigen-binding fragment thereof, and one or more maintenance doses are 200 mg of the antibody or antigen-binding fragment thereof administered biweekly.

In certain embodiments, the loading dose is 400 mg of anti-IL-4R antibody or antigen-binding fragment thereof, and one or more maintenance doses are 200 mg of antibody or antigen-binding fragment administered biweekly, which can be increased to 300 mg of antibody or its antigen-binding fragment, which is administered every two weeks.

In other embodiments, the loading dose is 600 mg of the anti-IL-4R antibody or antigen-binding fragment thereof, and one or more maintenance doses are 300 mg of the antibody or antigen-binding fragment thereof administered every four weeks.

In other embodiments, the loading dose is 400 mg of the anti-IL-4R antibody or antigen-binding fragment thereof, and one or more maintenance doses are 200 mg of the antibody or antigen-binding fragment thereof administered every four weeks.

In other embodiments, the loading dose is 600 mg of the anti-IL-4R antibody or antigen-binding fragment thereof, and one or more maintenance doses are 300 mg of the antibody or antigen-binding fragment thereof administered once a week.

In other embodiments, the loading dose is 400 mg of the anti-IL-4R antibody or antigen-binding fragment thereof, and one or more maintenance doses are 200 mg of the antibody or antigen-binding fragment thereof administered once a week.

In other embodiments, the loading dose is 600 mg of the anti-IL-4R antibody or antigen-binding fragment thereof, and one or more maintenance doses are 300 mg of the antibody or antigen-binding fragment thereof administered every three weeks.

In other embodiments, the loading dose is 400 mg of an anti-IL-4R antibody or antigen-binding fragment thereof, and one or more maintenance doses are 200 mg of the antibody or antigen-binding fragment thereof administered every three weeks.

In one embodiment, the subject is between 6 and <18 years of age and the anti-IL-4R antibody or antigen-binding fragment thereof is administered at a dose of 2 mg/kg or 4 mg/kg.

In another embodiment, the subject is between 12 and <18 years of age and the anti-IL-4R antibody or antigen-binding fragment thereof is administered at a dose of 2 mg/kg or 4 mg/kg.

In another embodiment, the subject is between 6 and <12 years of age and the anti-IL-4R antibody or antigen-binding fragment thereof is administered at a dose of 2 mg/kg or 4 mg/kg.

In another embodiment, the subject is 2 to < 6 years of age and the anti-IL-4R antibody or antigen-binding fragment thereof is administered at a dose of 2 mg/kg or 4 mg/kg.

In yet another embodiment, the subject is <2 years of age and the anti-IL-4R antibody or antigen-binding fragment thereof is administered at a dose of 2 mg/kg or 4 mg/kg.

Means of combination therapy

Certain embodiments of the methods of the present invention include administering to a subject one or more therapeutic agents in combination with an IL-4R antagonist. As used herein, "in combination with" means that additional therapeutic agents are administered before, after, or in parallel with the pharmaceutical composition containing the IL-4R antagonist. In some embodiments, the term "in combination with" includes the sequential or concomitant administration of an IL-4R antagonist and a second therapeutic agent. The present invention also includes methods for treating asthma or an associated condition or complication to reduce the incidence of at least one exacerbation, comprising administering an IL-4R antagonist in combination with a second therapeutic agent for additional or synergistic activity.

For example, when administered "before" a pharmaceutical composition containing an IL-4R antagonist, the additional therapeutic agent may be administered about 72 hours, about 60 hours, about 48 hours, about 36 hours, about 24 hours, about 12 hours, about 10 hours, about 8 hours, about 6 hours, about 4 hours, about 2 hours, about 1 hour, about 30 minutes, about 15 minutes, or about 10 minutes prior to administration of a pharmaceutical composition containing an IL-4R antagonist. When administered "after" a pharmaceutical composition containing an IL-4R antagonist, the additional therapeutic agent may be administered at about 10 minutes, about 15 minutes, about 30 minutes, about 1 hour, about 2 hours, about 4 hours, about 6 hours, about 8 hours, about 10 hours, about 12 hours, about 24 hours, about 36 hours, about 48 hours, about 60 hours, or about 72 hours after administration of a pharmaceutical composition containing an IL-4R antagonist. Administration "co-administered" with a pharmaceutical composition containing an IL-4R antagonist means that an additional therapeutic agent is administered to a subject in a separate dosage form within less than 5 minutes (before, after, or at the same time) of administration of a pharmaceutical composition containing an IL-4R antagonist. 4R, or administered to a subject in a single combined dosage formulation containing both an additional therapeutic agent and an IL-4R antagonist.

The additional therapeutic agent may be, for example, another IL-4R antagonist, an IL-1 antagonist (including, for example, an IL-1 antagonist as set forth in US Pat. No. 6,927,044), an IL-6 antagonist, an IL-6R antagonist (in including, for example, an anti-IL-6R antibody as set forth in US Pat. leukotriene, antifungal agent, NSAID, long-acting _beta2 -agonist (eg, salmeterol or formoterol), inhaled corticosteroid (eg, fluticasone or budesonide), systemic corticosteroid (eg, oral or intravenous), methylxanthine, nedocromil sodium, cromolyn sodium, or their combinations. For example, in certain embodiments, a pharmaceutical composition containing an IL-4R antagonist is administered in combination with a combination containing a long acting beta ₂ agonist and an inhaled corticosteroid (eg, fluticasone + salmeterol [eg, Advair® (GlaxoSmithKline)] or budesonide + formoterol [e.g. SYMBICORT® (Astra Zeneca)]).

Introduction schemes

In certain embodiments, multiple doses of the IL-4R antagonist may be administered to a subject over a period of time. These methods involve sequentially administering multiple doses of an IL-4R antagonist to a subject. As used herein, "sequential administration" means that each dose of an IL-4R antagonist is administered to a subject at a different point in time, e.g., on different days separated by a predetermined interval (e.g., hours, days, weeks, or months). The present invention includes methods that involve sequentially administering to a patient one initial dose of an IL-4R antagonist, followed by one or more secondary doses of an IL-4R antagonist, and then optionally one or more tertiary doses of an IL-4R antagonist.

The present invention includes methods comprising administering to a subject a pharmaceutical composition comprising an IL-4R antagonist at a dosing frequency of approximately four times a week, twice a week, once a week (q1w), once every two weeks (biweekly or q2w), once every three weeks (every three weeks or q3w), once every four weeks (monthly or q4w), once every five weeks (q5w), once every six weeks (q6w), once every eight weeks (q8w), once every twelve weeks (q12w), or less frequently until a therapeutic response is achieved. In certain embodiments involving the administration of a pharmaceutical composition comprising an anti-IL-4R antibody, administration of a dose of approximately 75 mg, 100 mg, 150 mg, 200 mg, or 300 mg once a week can be used. In other embodiments involving the administration of a pharmaceutical composition comprising an anti-IL-4R antibody, a dose of approximately 75 mg, 100 mg, 150 mg, 200 mg, or 300 mg once every other week may be used. In other embodiments involving the administration of a pharmaceutical composition comprising an anti-IL-4R antibody, administration of a dose of approximately 75 mg, 100 mg, 150 mg, 200 mg, or 300 mg once every three weeks may be used. In other embodiments involving the administration of a pharmaceutical composition comprising an anti-IL-4R antibody, a dose of approximately 75 mg, 100 mg, 150 mg, 200 mg, or 300 mg once every four weeks (monthly dosing) may be used. In other embodiments involving the administration of a pharmaceutical composition comprising an anti-IL-4R antibody, administration of a dose of approximately 75 mg, 100 mg, 150 mg, 200 mg, or 300 mg once every five weeks may be used. In other embodiments involving the administration of a pharmaceutical composition comprising an anti-IL-4R antibody, a dose of approximately 75 mg, 100 mg, 150 mg, 200 mg, or 300 mg once every six weeks may be used. In other embodiments involving the administration of a pharmaceutical composition comprising an anti-IL-4R antibody, administration of a dose of approximately 75 mg, 100 mg, 150 mg, 200 mg, or 300 mg once every eight weeks may be used. In other embodiments involving the administration of a pharmaceutical composition comprising an anti-IL-4R antibody, administration of a dose of approximately 75 mg, 100 mg, 150 mg, 200 mg, or 300 mg once every twelve weeks may be used. In other embodiments, the route of administration may be subcutaneous.

The term "week" or "weeks" refers to a period of (n x 7 days) ± 2 days, e.g. (n x 7 days) ± 1 day or (n x 7 days) where "n" is the number of weeks, e.g. 1, 2 , 3, 4, 5, 6, 8, 12 or more.

The terms "initial dose", "secondary doses" and "tertiary doses" refer to the time sequence of administration of the IL-4R antagonist. Thus, "starting dose" is the dose administered at the start of a treatment regimen (also referred to as "starting dose"); "secondary doses" are doses that are administered after the initial dose; and "tertiary doses" are doses that are administered after secondary doses. All of the initial, secondary and tertiary doses may contain the same amount of IL-4R antagonist, but, as a rule, may differ from each other in the frequency of administration. However, in certain embodiments, the amount of IL-4R antagonist contained in the initial, secondary, and/or tertiary doses varies from one another (eg, adjusted up or down as needed) throughout the course of treatment. In certain embodiments, two or more (eg, 2, 3, 4, or 5) doses are administered at the beginning of the treatment regimen as "loading doses", then subsequent doses are administered at a lesser frequency (eg, "maintenance doses"). In one embodiment, the maintenance dose may be lower than the loading dose. For example, one or more loading doses of 600 mg of an IL-4R antagonist may be administered after maintenance doses of about 75 mg to about 300 mg.

In certain embodiments, the loading dose of the IL-4R antagonist is from about 400 to about 600 mg. In one embodiment, the loading dose of the IL-4R antagonist is 400 mg. In another embodiment, the loading dose of the IL-4R antagonist is 600 mg.

In certain embodiments, the maintenance dose of the IL-4R antagonist is from about 200 to about 300 mg. In one embodiment, the maintenance dose of the IL-4R antagonist is 200 mg. In another embodiment, the maintenance dose of the IL-4R antagonist is 300 mg.

In certain embodiments, the loading dose is twice the maintenance dose.

In some embodiments, the loading dose comprises 600 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses comprise 300 mg of the antibody or antigen-binding fragment thereof administered biweekly.

In some embodiments, the subject has OCS-dependent asthma and the loading dose is 600 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses are 300 mg of the antibody or antigen-binding fragment thereof administered biweekly.

In some embodiments, the subject has moderate to severe comorbid atopic dermatitis and the loading dose is 600 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses are 300 mg of the antibody or antigen-binding fragment thereof administered biweekly.

In some embodiments, the loading dose comprises 400 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses comprise 200 mg of the antibody or antigen-binding fragment thereof administered biweekly.

In some embodiments, the subject has OCS-dependent asthma and the loading dose is 400 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses are 200 mg of the antibody or antigen-binding fragment thereof administered biweekly.

In some embodiments, the subject has moderate to severe comorbid atopic dermatitis and the loading dose comprises 400 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses comprise 200 mg of the antibody or antigen-binding fragment thereof administered biweekly.

In some embodiments, the loading dose comprises 600 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses comprise 300 mg of the antibody or antigen-binding fragment thereof administered every four weeks.

In some embodiments, the subject has OCS-dependent asthma and the loading dose is 600 mg of the antibody or antigen-binding fragment thereof and one or more maintenance doses are 300 mg of the antibody or antigen-binding fragment thereof administered every four weeks.

In some embodiments, the subject has moderate to severe comorbid atopic dermatitis and the loading dose is 600 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses are 300 mg of the antibody or antigen-binding fragment thereof administered every four weeks.

In some embodiments, the loading dose comprises 400 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses comprise 200 mg of the antibody or antigen-binding fragment thereof administered every four weeks.

In some embodiments, the subject has OCS-dependent asthma and the loading dose is 400 mg of the antibody or antigen-binding fragment thereof and one or more maintenance doses are 200 mg of the antibody or antigen-binding fragment thereof administered every four weeks.

In some embodiments, the subject has moderate to severe comorbid atopic dermatitis and the loading dose is 400 mg of the antibody or antigen-binding fragment thereof, and one or more maintenance doses are 200 mg of the antibody or antigen-binding fragment thereof administered every four weeks.

In one exemplary embodiment, each secondary and/or tertiary dose is administered at 1-14 (e.g., 1, 1½, 2, 2½, 3, 3½, 4, 4½, 5, 5½, 6, 6½, 7, 7½, 8, 8½, 9, 9½, 10, 10½, 11, 11½, 12, 12½, 13, 13½, 14, 14½ or more) weeks after the immediately preceding dose. The term "immediately preceding dose" means, in a sequence of multiple doses, the dose of the IL-4R antagonist that is administered to the patient prior to the next next dose in the sequence without intermediate doses.

The methods may include administering to the patient any number of secondary and/or tertiary doses of the IL-4R antagonist. For example, in certain embodiments, only one secondary dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8 or more) secondary doses are administered to the patient. Similarly, in certain embodiments, only one tertiary dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8 or more) tertiary doses are administered to the patient.

In embodiments involving multiple secondary doses, each secondary dose may be administered at the same frequency as the other secondary doses. For example, each secondary dose may be administered to a patient 1-2 weeks after the immediately preceding dose. Similarly, in embodiments involving multiple tertiary doses, each tertiary dose may be administered at the same frequency as the remaining tertiary doses. For example, each tertiary dose may be administered to a patient 2-4 weeks after the immediately preceding dose. Alternatively, the frequency with which secondary and/or tertiary doses are administered to a patient may vary throughout the treatment regimen. The frequency of administration can be adjusted by the physician during the course of treatment, depending on the needs of the individual patient after clinical examination.

The present invention includes methods comprising sequentially administering to a patient an IL-4R antagonist and a second therapeutic agent for treating asthma or an associated condition. In some embodiments, the methods comprise administering one or more doses of an IL-4R antagonist followed by one or more doses (eg, 2, 3, 4, 5, 6, 7, 8 or more) of the second therapeutic agent. For example, one or more doses of the IL-4R antagonist can be administered, ranging from about 75 mg to about 300 mg, followed by one or more doses (e.g., 2, 3, 4, 5, 6, 7, 8 or more) a second therapeutic agent (for example, an inhaled corticosteroid or any beta2-agonist or any other therapeutic agent described elsewhere herein) to treat, alleviate, reduce the intensity or reduce the severity of one or more symptoms of asthma. In some embodiments, the IL-4R antagonist is administered at one or more doses (e.g., 2, 3, 4, 5, 6, 7, 8 or more) resulting in an improvement in one or more asthma-associated parameters, followed by administration a second therapeutic agent for preventing the recurrence of at least one symptom of asthma. Alternative embodiments relate to the concomitant administration of an IL-4R antagonist and a second therapeutic agent. For example, one or more doses (e.g., .2, 3, 4, 5, 6, 7, 8 or more) of the IL-4R antagonist are administered and the second therapeutic agent is administered in a separate dosage at the same or different frequency relative to the IL-4R antagonist. 4R. In some embodiments, the second therapeutic agent is administered before, after, or in conjunction with the IL-4R antagonist.

In certain embodiments, the IL-4R antagonist is administered biweekly for 12 weeks, 14 weeks, 16 weeks, 18 weeks, 20 weeks, 22 weeks, 24 weeks, 26 weeks, 28 weeks, 30 weeks, 32 weeks, 34 weeks , 36 weeks, 38 weeks, 40 weeks, 42 weeks, 44 weeks, 46 weeks, 48 weeks or more. In other embodiments, the IL-4R antagonist is administered every four weeks for 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or more. In specific embodiments, the IL-4R antagonist is administered for at least 24 weeks.

The present invention includes methods for treating a subject suffering from severe uncontrolled asthma (eg, severe steroid-dependent asthma) comprising administering to the subject a loading dose of an antibody, or antigen-binding fragment thereof, that specifically binds to IL-4R. In certain embodiments, the methods involve administering to a subject a plurality of maintenance doses of an antibody or antigen-binding fragment thereof, wherein the plurality of maintenance doses are administered during a treatment phase. The treatment phase includes an induction phase, an OCS reduction phase, and an OCS maintenance phase.

In certain exemplary embodiments, the induction phase includes a period during which subjects continuously receive their dose(s) of OCS. In certain exemplary embodiments, the taper phase includes a period during which subjects receive a lower dose of OCS compared to the dose received during the induction phase. In certain exemplary embodiments, the maintenance phase includes a period during which the subject receives a certain stable amount or dose(s) of OCS. Alternatively, the maintenance phase includes a period during which OCS therapy/administration is reduced or eliminated. In certain embodiments, the patient is completely off OCS and the patient is steroid-free for less than 1 year of anti-IL4R antibody or fragment thereof treatment (e.g., 1 year, 6 months, 3 months, or 1 month after initial treatment).

In another aspect, a method of treating a subject suffering from severe steroid-dependent asthma and/or severe uncontrolled asthma comprises administering to the subject a loading dose of approximately 600 mg of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) and administering the subject of multiple maintenance doses of the antibody or antigen-binding fragment. Each maintenance dose is approximately 300 mg of the antibody or antigen-binding fragment thereof, where multiple maintenance doses are administered during the treatment phase, comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and a maintenance phase, where the antibody or antigen-binding fragment thereof contains the severe and mild CDR sequences. strands from the HCVR/LCVR sequence pair providing for SEQ ID NOs: 1 and 2.

Treatment populations

The methods of the present invention involve administering to a subject in need thereof a therapeutic composition comprising an IL-4R antagonist. The expression "in need thereof" means a human or non-human animal who has one or more symptoms or manifestations of asthma (eg, moderate to severe uncontrolled asthma), or who has been diagnosed with asthma. For example, a "subject in need thereof" may include, for example, subjects who prior to treatment are (or were) characterized by one or more asthma-associated parameters, such as, for example, an impaired FEV ₁ (e.g., less than 2.0 L), an impaired FEF 25-75%; impaired PEF before noon (eg, less than 400 L/min), impaired PEF after noon (eg, less than 400 L/min), an ACQ5 score of at least 2.5, at least 1 nighttime awakening per a week and/or a SNOT-22 score of at least 20. In various embodiments, these methods can be used to treat mild, moderate to severe, or severe asthma in patients in need thereof. In certain embodiments, these methods can be used to treat mild, moderate to severe, or severe asthma in patients in need thereof, where the patients additionally have moderate to severe concomitant atopic dermatitis.

In a related embodiment, a "subject in need thereof" may be a subject who has been prescribed the ICS/LABA combination prior to receiving the IL-4R antagonist or is currently taking it. Examples of ICS include mometasone furoate, budesonide, and fluticasone propionate. Examples of LABAs include formoterol and salmeterol. Examples of ICS/LABA therapies include fluticasone/salmeterol combination therapy and budesonide/formoterol combination therapy. For example, the present invention includes methods that involve administering an IL-4R antagonist to a patient who has been on a regular course of ICS/LABA for two or more weeks immediately prior to administration of the IL-4R antagonist (such pretreatment agents are referred to herein as "background treatment agents"). "). The present invention includes therapeutic methods in which background treatment agents continue to be taken in combination with the administration of an IL-4R antagonist. In yet other embodiments, the amount of the ICS component, the LABA component, or both is gradually reduced before or after the start of administration of the IL-4R antagonist. In some embodiments, the present invention includes methods for treating patients with persistent asthma for at least ≥ 12 months. In one embodiment, a patient with persistent asthma may be refractory to treatment with a therapeutic agent, such as a corticosteroid, and may be administered an IL-4R antagonist according to the methods of the present invention.

In some embodiments, the "subject in need" may be a subject with elevated levels of an asthma-associated biomarker. Examples of asthma-associated biomarkers include, but are not limited to, IgE, thymus-activated chemokine (TARC), eotaxin-3, CEA, YKL-40, and periostin. In some embodiments, a "subject in need" may be a subject with a blood eosinophil count of ≥ 300 cells/µl, 200-299 cells/µl, or < 200 cells/µl. In one embodiment, a "subject in need" may be a subject with an increased level of inflammation in the bronchi or airways, as measured by the fraction of exhaled nitric oxide (FeNO).

In some embodiments, the subject in need thereof is selected from the group consisting of a subject 18 years of age or older, a subject 12 years of age or older, a subject 12 to 17 years of age (12 to < 18 years of age), a subject 6 years of age or older up to 11 years of age (6 to < 12 years) and a subject aged 2 to 5 years (2 to < 6 years). In some embodiments, the "subject in need" is selected from the group consisting of an adult, a teenager, and a child. In some embodiments, the "subject in need thereof" is selected from the group consisting of an adult human 18 years of age or older, an adolescent 12 to 17 years of age (12 to < 18 years of age), a child of 6 to 11 years of age (from 6 to < 12 years) and a child aged 2 to 5 years (2 to < 6 years). The age of the subject may be less than 2 years, such as 12 to 23 months or 6 to 11 months.

Normal IgE levels in healthy subjects are less than about 100 kU/L (eg, as measured by the IMMUNOCAP® assay [Phadia Inc., Portage, MI]). Thus, the present invention includes methods comprising selecting a subject that has an elevated serum IgE level, wherein the serum IgE level is greater than about 100 kU/L, greater than about 150 kU/L, greater than about 500 kU/L, more than about 1000 kU/L, more than about 1500 kU/L, more than about 2000 kU/L, more than about 2500 kU/L, more than about 3000 kU/L, more than about 3500 kU/L, more than about 4000 kU/L, more about 4500 kU/L or greater than about 5000 kU/L, and administering to the subject a pharmaceutical composition containing a therapeutically effective amount of an IL-4R antagonist.

TARC levels in healthy subjects range from 106 ng/L to 431 ng/L, with a mean value of approximately 239 ng/L. (An exemplary assay system for measuring TARC is the TARC quantification ELISA kit available under Cat. No. DDN00 from R&D Systems, Minneapolis, MN.) serum TARC level greater than about 431 ng/l, greater than about 500 ng/l, greater than about 1000 ng/l, greater than about 1500 ng/l, greater than about 2000 ng/l, greater than about 2500 ng greater than about 3000 ng/l, greater than about 3500 ng/l, greater than about 4000 ng/l, greater than about 4500 ng/l, or greater than about 5000 ng/l, and administering to the subject a pharmaceutical composition containing a therapeutically effective amount of an IL antagonist -4R.

Eotaxin-3 belongs to a group of chemokines released by airway epithelial cells that is positively regulated by the Th2 cytokines IL-4 and IL-13 (Lilly et al 1999, J. Allergy Clin. Immunol. 104: 786-790). The present invention includes methods comprising administering an IL-4R antagonist to treat patients with elevated levels of eotaxin-3, e.g., greater than about 100 pg/ml, greater than about 150 pg/ml, greater than about 200 pg/ml, greater than about 300 pg/ml or more than about 350 pg/ml. Serum levels of eotaxin-3 can be measured, for example, by ELISA.

Periostin is an extracellular matrix protein involved in Th2-mediated inflammatory processes. Periostin levels have been found to be elevated in patients with asthma (Jia et al 2012 J Allergy Clin Immunol. 130:647-654.e10. doi: 10.1016/j.jaci.2012.06.025. electronic publication August 1, 2012). The present invention includes methods for administering an IL-4R antagonist to treat patients with elevated periostin levels.

Fractional exhaled NO (FeNO) is a biomarker for bronchial or airway inflammation. FeNO is produced by airway epithelial cells in response to inflammatory cytokines, including IL-4 and IL-13 (Alwing et al 1993, Eur. Respir. J. 6: 1368-1370). FeNO levels in healthy adults range from 2 to 30 parts per billion (ppb). An exemplary assay for measuring FeNO is using the NIOX device Aerocrine AB, Solna, Sweden. The assessment can be done before spirometry or after fasting for at least an hour. The present invention includes methods comprising administering an IL-4R antagonist to patients with elevated levels of exhaled NO (FeNO), such as greater than about 30 ppb, greater than about 31 ppb, greater than about 32 ppb, greater than about 33 ppb, greater than about 34 ppb, or greater than about 35 ppb.

Cancer embryonic antigen (CEA) (also known as cell adhesion molecule 5 CEA [CEACAM5]) is a tumor marker that has been found to be associated with non-neoplastic lung diseases (Marechal et al 1988, Anticancer Res. 8:677- 680). Serum CEA levels can be measured by ELISA. The present invention includes methods comprising administering an IL-4R antagonist to patients with elevated levels of CEA, for example, greater than about 1.0 ng/ml, greater than about 1.5 ng/ml, greater than about 2.0 ng/ml, greater than about 2, 5 ng/ml, greater than about 3.0 ng/ml, greater than about 4.0 ng/ml, or greater than about 5.0 ng/ml.

YKL-40 (named for its N-terminal amino acids tyrosine (Y), lysine (K), and leucine (L) and its 40 kDa molecular weight) is a chitinase-like protein found to be upregulated and associated with flare-ups. asthma, IgE and eosinophils (Tang et al 2010 Eur. Respir. J. 35: 757-760). Serum levels of YKL-40 are measured, for example, by ELISA. The present invention includes methods comprising administering an IL-4R antagonist to patients with elevated YKL-40 levels of, for example, greater than about 40 ng/ml, greater than about 50 ng/ml, greater than about 100 ng/ml, greater than about 150 ng/ml , greater than about 200 ng/ml, or greater than about 250 ng/ml.

Periostin is a secreted extracellular matrix protein associated with fibrosis, and its expression is positively regulated by recombinant IL-4 and IL-13 in cultured bronchial epithelial cells and bronchial fibroblasts (Jia et al. (2012) J. Allergy Clin. Immunol.130: 647). In human patients with asthma, periostin expression levels are associated with reticular basement membrane thickness, an indicator of subepithelial fibrosis. There. The present invention includes methods for administering an IL-4R antagonist to patients with elevated periostin levels.

Eosinophils and neutrophils from induced sputum are commonly accepted direct markers of airway inflammation (Djukanovic et al 2002, Eur. Respire. J. 37: 1S-2S). Sputum production is induced by inhalation of hypertonic saline and the cells are counted according to methods known in the art, for example according to the guidelines of the European Respiratory Society.

In some embodiments, subjects are divided into the following groups: blood eosinophil count (high blood eosinophil count) ≥ 300 cells/µl (HEo), or 300-499 cells/µl, or ≥ 500 cells/µl, blood eosinophil count 200 -299 cells/µl (moderate eosinophils), or blood eosinophils < 200 cells/µl (low eosinophils), and the administration of an antibody to IL-4R or its antigen-binding fragment is carried out in a dose or according to the administration schedule based on the level of eosinophils.

In some embodiments, subjects are divided into the following groups: blood eosinophils ≥ 300 cells/µl, 300-499 cells/µl, or ≥ 500 cells/µl (high blood eosinophils); the content of eosinophils in the blood ≥ 150 cells / µl (moderate content of eosinophils); or blood eosinophils < 150 cells/µl (low eosinophils), and anti-IL-4R antibody or antigen-binding fragment thereof is administered at a dose or schedule based on eosinophil levels.

In some embodiments, the subject has "eosinophilic phenotype" asthma, defined as blood eosinophils ≥ 150 cells/μL, blood eosinophils ≥ 300 cells/μL, blood eosinophils 300-499 cells/μL, or blood eosinophils ≥ 500 cells/µl, and he is injected with an antibody to IL-4R or its antigen-binding fragment.

Methods for determining asthma-associated pharmacodynamic parameters

The present invention includes methods for determining one or more asthma-associated pharmacodynamic parameters in a subject in need thereof elicited by administration of a pharmaceutical composition comprising an IL-4R antagonist. A reduction in the frequency of asthma exacerbation (as described above) or an improvement in one or more asthma-associated parameters (as described above) may be associated with an improvement in one or more pharmacodynamic asthma-associated parameters; however, such a relationship is not necessarily observed in all cases.

Examples of "asthma-associated pharmacodynamic parameters" include, for example, the following: (a) expression levels of biomarkers; (b) analysis of serum proteins and RNA; (c) eosinophil and neutrophil levels of induced sputum; (d) exhaled nitric oxide (FeNO) and (e) blood eosinophil count. "Improvement in an asthma-associated pharmacodynamic parameter" means, for example, a decrease from baseline in one or more biomarkers such as TARC, eotaxin-3, or IgE, a decrease in sputum eosinophils or neutrophils, FeNO, periostin, or blood eosinophils. As used herein, the term "baseline" in relation to an asthma-associated pharmacodynamic parameter means the numerical value of an asthma-associated pharmacodynamic parameter for a patient before or during the entire period of administration of the pharmaceutical composition described herein.

To evaluate an asthma-associated pharmacodynamic parameter, the parameter is quantified at baseline and at a time point following administration of the pharmaceutical composition. For example, an asthma-associated pharmacodynamic parameter can be measured on day 1, day 2, day 3, day 4, day 5, day 6, day 7, day 8, day 9, day 10, day 11, day 12, day 14, or on Week 3, Week 4, Week 5, Week 6, Week 7, Week 8, Week 9, Week 10, Week 11, Week 12, Week 13, Week 14, Week 15, Week 16, Week 17, Week 18, Week 19 , week 20, week 21, week 22, week 23, week 24, or longer after primary treatment with the pharmaceutical composition. The difference between the parameter value at a certain time point after the start of treatment and the parameter value at baseline is used to establish whether a change has occurred, such as an "improvement" in an asthma-associated pharmacodynamic parameter (e.g., increase or decrease, depending on the situation, depending on on the specific parameter being measured).

In certain embodiments, administration of an IL-4R antagonist to a patient causes a change, such as a decrease or increase in the expression of a particular biomarker. Asthma-associated biomarkers include, without limitation, the following: (a) total IgE; (b) thymus-activated chemokine (TARC); (c) YKL-40; (d) cancer-embryonic antigen in blood serum; (e) eotaxin-3 in plasma; and (f) periostin in serum. For example, administration of an IL-4R antagonist to a patient with asthma may cause one or more of a decrease in TARC or eotaxin-3 levels or a decrease in serum total IgE levels. A decrease can be detected at week 1, week 2, week 3, week 4, week 5, or later after administration of the IL-4R antagonist. Expression of biomarkers can be determined by methods known in the art. For example, protein levels can be measured using ELISA (enzyme-linked immunosorbent assay). RNA levels can be measured, for example, using reverse transcription linked polymerase chain reaction (RT-PCR).

Expression of the biomarkers described above can be determined by detecting protein or RNA in serum. Serum samples can also be used to monitor additional protein or RNA biomarkers associated with response to IL-4R antagonist treatment, IL-4/IL-13 signaling, asthma, atopy, or eosinophilic disease (eg, by measuring soluble IL -4Rα, IL-4, IL-13, periostin). In some embodiments, RNA samples are used to determine RNA levels (non-genetic analysis), such as RNA levels of biomarkers; and in other embodiments, the RNA samples are used for transcriptome sequencing (eg, genetic analysis).

Lineups

In some embodiments, the antibody or antigen-binding fragment thereof is in a composition comprising i) about 150 mg/ml of the antibody or antigen-binding fragment thereof that specifically binds to IL-4R, ii) about 20 mM histidine, iii) about 12.5 mM acetate , iv) about 5% (w/v) sucrose, v) about 25 mM arginine hydrochloride, vi) about 0.2% (w/v) polysorbate 80, where the pH of the composition is about 5.9, and where the viscosity of the composition is approximately 8.5 centipoise.

In alternative embodiments, the antibody or antigen-binding fragment thereof is formulated in a composition comprising i) about 175 mg/ml of the antibody or antigen-binding fragment thereof that specifically binds to IL-4R, ii) about 20 mM histidine, iii) about 12.5 mM acetate , iv) about 5% (w/v) sucrose, v) about 50 mM arginine hydrochloride, vi) about 0.2% (w/v) polysorbate 80, where the pH of the composition is about 5.9, and where the viscosity of the composition is approximately 8.5 centipoise.

In specific embodiments, the antibody or antigen-binding fragment thereof comprises an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and an LCVR comprising the amino acid sequence of SEQ ID NO: 2.

The present invention is further illustrated by the following examples, which should not be construed as a further limitation. The contents of the drawings and all references, patents and published patent applications cited in this application are incorporated herein by reference in their entirety for all purposes.

In addition, conventional molecular biology, microbiology, and recombinant DNA techniques can be used in accordance with the present invention within the skill of the art. Such techniques are fully explained in the literature. See, for example, Green & Sambrook, Molecular Cloning: A Laboratory Manual, Fourth Edition (2012) Cold Spring Harbor Laboratory Press, Cold Spring Harbor, New York; DNA Cloning: A Practical Approach, Volumes I and II (D.N. Glover ed. 1985); Oligonucleotide Synthesis (M. J. Gait ed. 1984); Nucleic Acid Hybridization [B.D. Hames & S.J. Higgins eds. (1985)]; Transcription And Translation [B.D. Hames & S.J. Higgins, eds. (1984)]; Animal Cell Culture [R.I. Freshney, ed. (1986)]; Immobilized Cells And Enzymes [IRL Press, (1986)]; B. Perbal, A Practical Guide To Molecular Cloning (1984); F.M. Ausubel et al. (eds.), Current Protocols in Molecular Biology, John Wiley & Sons, Inc. (1994).

EXAMPLES

The following examples are set forth to provide those skilled in the art with a complete disclosure and description of the preparation and use of the methods and compositions described herein, and are not intended to limit the scope of what the present inventors consider to be their invention. Efforts have been made to ensure accuracy with respect to the numbers used (eg amounts, temperatures, etc.), however, some experimental errors and deviations must be taken into account. Unless otherwise indicated, parts are parts by weight, molecular weight is average molecular weight, temperature is in degrees Celsius, and pressure is atmospheric or near atmospheric.

An exemplary IL-4R antagonist used in the following examples is the human anti-IL-4R antibody dupilumab (also referred to herein as "mAb1").

Example 1 Phase III trial of the VENTURE study (NCT02528214)

Severe uncontrolled asthma can lead to dependence on oral corticosteroids with systemic steroid exposure. This can potentially lead to serious short and long term adverse effects including weight gain, diabetes, osteoporosis, glaucoma, anxiety, depression, cardiovascular disease and immunosuppression. Patients with severe chronic asthma live with a profound decline in lung function, about 52 percent of the predicted normal level for those at baseline in this study. Decreased lung function affects their ability to breathe normally and can lead to frequent exacerbations requiring emergency treatment and hospitalization. These problems occur even in patients treated with systemic administration of OCS.

A phase 3 trial/study was conducted to evaluate investigational dupilumab in adults and adolescents with severe steroid-dependent asthma without minimum blood eosinophil requirements, receiving an additional 300 mg of dupilumab or placebo every 2 weeks for 24 weeks. The phase 3 trial (VENTURE) included 210 patients (203 completed the randomized treatment period, 101 in the dupilumab group and 102 in the placebo group) with severe asthma and regular OCS maintenance during the six months prior to the study (Figure 1). In this study, the prescribed OCS was prednisone or prednisone. Patients were randomized using a 1:1 randomization ratio and treated with either dupilumab, 300 mg biweekly with a 600 mg loading dose, or placebo (FIG. 2). The median baseline eosinophil count in this study was 260 eosinophils/microliter. The primary endpoint was glucocorticoid dose reduction at week 24. Key secondary endpoints included the proportion of patients achieving a 50% reduction in glucocorticoid dose and a reduction in glucocorticoid dose to 5 mg/day at week 24. Severe exacerbation rate and forced expiratory volume in 1 second ( FEV ₁ ) prior to bronchodilator administration was evaluated in the general population and in patients with blood eosinophil counts ≥ 300 cells/µl. Safety was assessed as a whole.

Inclusion criteria for this study are summarized in Table 1 below. The baseline demographics for the study are shown in FIG. 3.

Table 1. Inclusion criteria.

VENTURE Study Age Adults and adolescents, >= 12 years history of asthma At least 6 months documented need for OCS (equivalent to GINA 5 - severe) Available asthma treatment High doses of ICS
Daily dose of OCS: from a minimum of 5 mg to a maximum of 35 mg
No more than 3 control drugs are allowed. FEV ₁ to BD <= 80% for adults; <= 90% for teenagers ACQ-5 Not indicated FEV ₁ reversibility Documented history for the previous year Number of severe exacerbations in the previous year Not indicated

Exclusion criteria for the Venture study were also applied; the exclusion criterion for patients was EOS < 150, limited to no more than 25% of the general population.

The primary endpoint analyzed was percentage reduction in OCS dose at week 24. Key secondary endpoints analyzed included a reduction in OCS dose of 50% or more and a reduction in OCS dose to <5 mg/day. Other secondary endpoints studied included the patient achieving the maximum possible reduction according to the protocol and no further need for OCS. Disease-specific efficacy criteria were used. The criteria were year-over-year reduction in severe exacerbation and improvement in lung function (FEV ₁ ). In FIG. 2 shows the overall distribution of patients in the study.

primary outcome

In the Intent-to-Treat (ITT) population, dupilumab treatment significantly reduced oral glucocorticoid dose compared to placebo while maintaining asthma control: least-squares (LS) mean (standard error [SE]) percentage change from baseline to weeks 24 (−70.1% (4.90) vs. −41.9% (4.57) of baseline, respectively (P < 0.001; Fig. 4A; Table 2)). The observed median change from baseline to week 24 in patients treated with dupilumab was 100% (interquartile range (IQR) 62.5% to 100%) versus 50% (IQR 0% to 100%) in the placebo group .

Table 2 Summary of outcomes at week 24 - ITT population.

Placebo (N=107) 300 mg dupilumab q2w (N=103) Percentage reduction from baseline in oral glucocorticoid dose at week 24 Change in mean value determined by LS (SE) −41.85 (4.57) −70.09 (4.90) Difference in mean value determined by LS compared to placebo (95% CI) -28.24 (-40.67 to -15.81) P-value versus placebo <0.001 Median decline (IQR) ^a -50 (from -100 to 0) -100 (from -100 to -62.50) 100% 29.0 52.4 ≥90% 30.8 55.3 ≥75% 39.3 68.9 ≥50% 53.3 79.6 0% 68.2 86.4 No reduction or increase in glucocorticoid dose, or dropped out of the study 31.8 13.6 Dose reduction of oral glucocorticoid (mg/day) from baseline at week 24 Change in mean value determined by LS (SE) −4.77 (0.54) −7.58 (0.58) Difference in mean value determined by LS compared to placebo (95% CI) -2.81 (from -4.29 to -1.33) P-value versus placebo <0.001 Proportion of patients with ≥ 50% dose reduction of oral glucocorticoid at week 24 Yes - qty (%) 57 (53.3) 82 (79.6) Estimate (95% CI) 0.50 (from 0.40 to 0.61) 0.80 (from 0.70 to 0.87) Hazard ratio versus placebo (95% CI) 3.98 (from 2.06 to 7.67) P-value versus placebo <0.001 Proportion of patients with reduction of oral glucocorticoid to < 5 mg/day at week 24 Yes - qty (%) 40 (37.4) 74 (71.8) Estimate (95% CI) 0.33 (from 0.24 to 0.44) 0.69 (from 0.58 to 0.79) Hazard ratio versus placebo (95% CI) 4.48 (from 2.39 to 8.39) P-value versus placebo <0.001 Proportion of patients no longer needing oral glucocorticoid at week 24 Yes - qty (%) 31 (29.2) 54 (52.4) Estimate (95% CI) 0.25 (from 0.17 to 0.35) 0.48 (from 0.36 to 0.59) Hazard ratio versus placebo (95% CI) 2.74 (from 1.47 to 5.10) P-value versus placebo 0.002 Proportion of patients with the highest possible dose of oral glucocorticoid at week 24 Yes - qty (%) 32 (29.9) 54 (52.4) Estimate (95% CI) 0.26 (from 0.18 to 0.36) 0.48 (from 0.36 to 0.59) Hazard ratio versus placebo (95% CI) 2.57 (from 1.40 to 4.73) P-value versus placebo 0.002 Adjusted annualized frequency of severe exacerbation events during the 24-week treatment period Estimate (95% CI) 1.597 (from 1.248 to 2.043) 0.649 (from 0.442 to 0.955) Relative risk versus placebo (95% CI) 0.407 (from 0.263 to 0.630) P-value versus placebo <0.001 Change from Baseline FEV ₁ (L) to Bronchodilator Administration at Week 24 Change in mean value determined by LS (SE) - l 0.01 (0.05) 0.22 (0.05) Difference in mean value determined by LS compared to placebo (95% CI) 0.22 (from 0.09 to 0.34) P-value versus placebo <0.001 Change from baseline FeNO (ppb) at week 24 Change in mean value (SE) - ppb 0.3 (27.9) −17.3 (27.9) P-value versus placebo ^b <0.001

CI stands for confidence interval, FeNO - fraction of nitric oxide in exhaled air, FEV ₁ - forced expiratory volume in 1 second, IQR - interquartile interval, LS - least squares method, ppb - parts per billion, q2w - every 2 weeks, SD - standard deviation, and SE - standard error. ^a Calculated from observed data only. ^b FeNO was tested non-parametrically.

Secondary Outcomes

Outcomes of reduced glucocorticoids

For the primary endpoint, at 24 weeks in the general population, adding dupilumab to standard therapy significantly reduced maintenance oral glucocorticoids (OCS) by 70.1% (median 100 percent) compared with 41.9% with placebo (median 50 percent) (p < 0.001).

In predefined analyzes of patients with baseline eosinophils of 300 cells/microliter or more, the addition of dupilumab significantly reduced OCS use by an average of 80 percent (median 100 percent) compared with 43 percent for placebo (median 50 percent).

The proportion of patients achieving ≥ 50% reduction in oral glucocorticoid dose from baseline at week 24 was significantly higher with dupilumab compared with placebo (80% versus 50%; P < 0.001; observed values: 80% for dupilumab, 53% for placebo) (Fig. 4A; table 2). Sensitivity analyzes also showed a large proportion of patients with 50%, 75%, and 90% reductions in oral glucocorticoids with dupilumab (Table 3). Significantly more patients treated with dupilumab compared with placebo achieved dose reductions of oral glucocorticoid to < 5 mg/day (69% versus 33%; P < 0.001; observed values: 72% for dupilumab, 37% for placebo) (Fig. .4A, table 2).

Table 3. Sensitivity analyzes: Percent dose reduction of oral glucocorticoid (mg/day) at week 24 analyzed by proportional hazards model - ITT population.

Percentage reduction from baseline oral glucocorticoid dose at week 24 Placebo (N=107) 300 mg dupilumab q2w (N=103) ≥90% 33 (30.8) 57 (55.3) ≥75% 42 (39.3) 71 (68.9) ≥50% 57 (53.3) 82 (79.6) >0% 73 (68.2) 89 (86.4) No reduction or any increase in oral glucocorticoid dose, or dropped out of the study 34 (31.8) 14 (13.6) Hazard ratio versus placebo (95% CI) 3.25 (from 1.90 to 5.55) P-value versus placebo <0.001

Data are mean (SD) or count (%). CI is the confidence interval, q2w is every 2 weeks, and ITT is the prescribed treatment. The percentage reduction in oral glucocorticoid dose at week 24 was classified into five ordinal categories (90% to 100%, 75% to < 90%, 50% to < 75%, > 0% to < 50%, no reduction or no reduction). either increasing the dose of oral glucocorticoid, or dropped out of the study). The model used endpoint category as the dependent variable and treatment group, baseline-optimized oral glucocorticoid dose, regions, and subgroups based on baseline blood eosinophil levels (≥ 150 cells/mcL or < 150 cells/mcL) as covariates.

Notably, 48% of patients treated with dupilumab compared with 26% of patients treated with placebo achieved the maximum possible dose reduction of glucocorticoids at week 24 (P = 0.002; observed values: 52% for dupilumab, 30% for placebo ) (Fig. 4A; table 2). Similarly, 48% of patients treated with dupilumab versus 25% of patients treated with placebo no longer required oral glucocorticoids at week 24 (P = 0.002; observed values: 52% for dupilumab, 29% for placebo ) (Fig. 4A; table 2). Dupilumab provided consistent reductions in oral glucocorticoid outcomes regardless of baseline blood eosinophils (Figure 5A and Figure 5B; Table 4).

Table 4. Subgroup endpoint analyzes for oral glucocorticoid at week 24 by subgroup based on baseline blood eosinophil count.

Placebo (N=107) 300 mg dupilumab q2w (N=103) Percentage reduction from baseline in oral glucocorticoid dose (mg/day) The initial content of eosinophils in the blood ≥ 300 cells / µl - number 41 47 Change in mean value determined by LS (SE) −42.71 (6.77) −79.54 (6.36) Difference in mean value determined by LS compared to placebo (95% CI) -36.83 (from -54.71 to -18.94) The initial content of eosinophils in the blood < 300 cells / µl - number 65 54 Change in mean value determined by LS (SE) −44.98 (6.00) −66.31 (6.47) Difference in mean value determined by LS compared to placebo (95% CI) -21.33 (from -38.75 to -3.90) Overall P-value of the interaction 0.238 The initial content of eosinophils in the blood ≥ 150 cells / µl 69 80 Change in mean value determined by LS (SE) −46.51 (5.21) −75.91 (4.76) Difference in mean value determined by LS compared to placebo (95% CI) -29.39 (from -43.12 to -15.67) The initial content of eosinophils in the blood < 150 cells / µl - number 37 21 Change in mean value determined by LS (SE) −36.87 (8.60) −63.77 (11.14) Difference in mean value determined by LS compared to placebo (95% CI) -26.89 (from -54.52 to 0.73) Overall P-value of the interaction 0.708 Patients with ≥ 50% dose reduction of oral glucocorticoid The initial content of eosinophils in the blood ≥ 300 cells / µl - number 41 48 Estimate (95% CI) 0.52 (from 0.36 to 0.68) 0.88 (from 0.74 to 0.95) Hazard ratio versus placebo (95% CI) 6.59 (from 2.13 to 20.42) The initial content of eosinophils in the blood < 300 cells / µl - number 66 55 Estimate (95% CI) 0.52 (from 0.40 to 0.65) 0.76 (from 0.63 to 0.86) Hazard ratio versus placebo (95% CI) 2.91 (from 1.28 to 6.63) Overall P-value of the interaction 0.296 The initial content of eosinophils in the blood ≥ 150 cells / µl - number 69 81 Estimate (95% CI) 0.53 (from 0.41 to 0.65) 0.84 (from 0.74 to 0.90) Hazard ratio versus placebo (95% CI) 4.49 (from 2.04 to 9.85) The initial content of eosinophils in the blood < 150 cells / µl - number 38 22 Estimate (95% CI) 0.47 (from 0.31 to 0.64) 0.75 (from 0.52 to 0.89) Hazard ratio versus placebo (95% CI) 3.33 (from 0.97 to 11.48) Overall P-value of the interaction 0.493 Patients with reduced oral glucocorticoid to < 5 mg/day The initial content of eosinophils in the blood ≥ 300 cells / µl - number 41 48 Estimate (95% CI) 0.40 (from 0.25 to 0.57) 0.84 (from 0.70 to 0.92) Hazard ratio versus placebo (95% CI) 8.04 (from 2.71 to 23.82) The initial content of eosinophils in the blood < 300 cells / µl - number 66 55 Estimate (95% CI) 0.35 (from 0.24 to 0.48) 0.63 (from 0.49 to 0.75) Hazard ratio versus placebo (95% CI) 3.12 (from 1.41 to 6.93) Overall P-value of the interaction 0.226 The initial content of eosinophils in the blood ≥ 150 cells / µl - number 69 81 Estimate (95% CI) 0.44 (from 0.32 to 0.57) 0.77 (from 0.66 to 0.85) Hazard ratio versus placebo (95% CI) 4.29 (from 2.04 to 9.04) The initial content of eosinophils in the blood < 150 cells / µl - number 38 22 Estimate (95% CI) 0.21 (from 0.10 to 0.38) 0.62 (from 0.39 to 0.80) Hazard ratio versus placebo (95% CI) 6.03 (from 1.70 to 21.44) Overall P-value of the interaction 0.826 Proportion of patients no longer needing oral glucocorticoid The initial content of eosinophils in the blood ≥ 300 cells / µl - number 40 48 Estimate (95% CI) 0.26 (from 0.13 to 0.44) 0.59 (from 0.41 to 0.74) Hazard ratio versus placebo (95% CI) 4.07 (from 1.46 to 11.33) The initial content of eosinophils in the blood < 300 cells / µl - number 66 55 Estimate (95% CI) 0.26 (from 0.16 to 0.38) 0.43 (from 0.30 to 0.57) Hazard ratio versus placebo 2.15 (from 0.96 to 4.81) Overall P-value of the interaction 0.413 The initial content of eosinophils in the blood ≥ 150 cells / µl - number 68 81 Estimate (95% CI) 0.30 (from 0.19 to 0.43) 0.54 (from 0.42 to 0.66) Hazard ratio versus placebo (95% CI) 2.73 (from 1.31 to 5.70) The initial content of eosinophils in the blood < 150 cells / µl - number 38 22 Estimate (95% CI) 0.19 (from 0.09 to 0.35) 0.42 (from 0.23 to 0.65) Hazard ratio versus placebo (95% CI) 3.15 (from 0.93 to 10.73) Overall P-value of the interaction 0.966 Proportion of patients with the highest possible dose of oral glucocorticoid The initial content of eosinophils in the blood ≥ 300 cells / µl - number 41 48 Estimate (95% CI) 0.31 (from 0.18 to 0.48) 0.59 (from 0.43 to 0.74) Hazard ratio versus placebo (95% CI) 3.26 (from 1.26 to 8.43) The initial content of eosinophils in the blood < 300 cells / µl - number 66 55 Estimate (95% CI) 0.26 (from 0.16 to 0.38) 0.43 (from 0.30 to 0.57) Hazard ratio versus placebo (95% CI) 2.15 (from 0.96 to 4.81) Overall P-value of the interaction 0.544 The initial content of eosinophils in the blood ≥ 150 cells / µl - number 69 81 Estimate (95% CI) 0.32 (from 0.21 to 0.45) 0.54 (from 0.42 to 0.65) Hazard ratio versus placebo (95% CI) 2.47 (from 1.21 to 5.02) The initial content of eosinophils in the blood < 150 cells / µl - number 38 22 Estimate (95% CI) 0.19 (from 0.09 to 0.35) 0.42 (from 0.23 to 0.65) Hazard ratio versus placebo (95% CI) 3.15 (from 0.93 to 10.73) Overall P-value of the interaction 0.842

CI is the confidence interval, LS is the least squares method, SE is the standard error, and q2w is every 2 weeks.

Although improvements were seen in all subgroups based on baseline blood eosinophil counts, treatment effect sizes were largest in individuals with higher baseline eosinophil counts (e.g., hazard ratio versus placebo in patients with ≥ 50% reduction in oral glucocorticoid dose was 6.59 (95% CI 2.1 to 20.4) for patients with ≥ 300 cells/μL and 2.91 (95% CI 1.3 to 6.6) for patients with < 300 cells/μL at baseline) . In the general population, 69 percent of dupilumab-treated patients were able to reduce their OCS dose to less than 5 mg daily while maintaining asthma control compared to 33 percent of placebo patients (p <0.0001); in the high EOS group, 84 percent of dupilumab patients were able to reduce their OCS dose to less than 5 mg per day compared to 40 percent for placebo. (p equals 0.0002.) Half of the patients completely eliminated the use of oral glucocorticoid. Despite a decrease in glucocorticoid levels, dupilumab compared with placebo in the general population and in the subgroup of EOS ≥ 300 cells/μL provided a reduction in severe exacerbations by 59.3% (P < 0.001) and 71.1% and an improvement in FEV ₁ by 0.22 l (P < 0.001) and 0.32 l, respectively.

Exacerbations and FEV ₁

In addition to a significant reduction in oral glucocorticoid use during the 24-week treatment period, dupilumab provided a significant (P < 0.001) reduction in severe asthma exacerbations compared with placebo by 59.3% in the overall population (Fig. 4B and Table 7), as well as provided an improvement in FEV ₁ by a mean value determined by LS (SE) of 0.22 L (0.05) (relative to 0.01 L [0.05] in the placebo group, P < 0.001) at week 24 in the general population. Although dupilumab provided a year-over-year reduction in severe asthma exacerbations and an improvement in FEV ₁ compared with placebo regardless of baseline eosinophil counts (Figure 6A and Figure 6B, Table 5), these benefits were more pronounced in patients with higher baseline eosinophil counts. in blood. For example, dupilumab provided a 71.1% reduction in severe exacerbations and an improvement in FEV ₁ by a mean LS (SE) of 0.32 L (95% CI 0.10 to 0.54) (both P < 0.001 vs. placebo) in patients with baseline blood eosinophils ≥ 300 cells/µl.

Table 5. Exacerbation analyzes and change in FEV ₁ before bronchodilator administration in subgroups at week 24 by subgroup based on baseline blood eosinophils.

Placebo (N=107) 300 mg dupilumab q2w (N=103) Annualized frequency of severe exacerbations The initial content of eosinophils in the blood ≥ 300 cells / µl - number 41 48 Estimate (95% CI) 1.742 (from 1.202 to 2.525) 0.504 (from 0.260 to 0.975) Relative risk versus placebo (95% CI) 0.289 (from 0.139 to 0.601) The initial content of eosinophils in the blood < 300 cells / µl - number 66 55 Estimate (95% CI) 1.440 (from 1.045 to 1.984) 0.784 (from 0.502 to 1.226) Relative risk versus placebo (95% CI) 0.545 (0.315 to 0.940) Overall P-value of the interaction 0.143 The initial content of eosinophils in the blood ≥ 150 cells / µl - number 69 81 Estimate (95% CI) 1.536 (from 1.139 to 2.071) 0.642 (from 0.425 to 0.971) Relative risk versus placebo (95% CI) 0.418 (from 0.254 to 0.689) The initial content of eosinophils in the blood < 150 cells / µl - number 38 22 Estimate (95% CI) 1.537 (from 1.009 to 2.342) 0.609 (from 0.276 to 1.340) Relative risk versus placebo (95% CI) 0.396 (from 0.166 to 0.946) Overall P-value of the interaction 0.824 FEV ₁ (l) before the introduction of a bronchodilator Baseline blood eosinophils ≥ 300 cells/µl Baseline - no. 41 48 Average initial level (SD) - l 1.57 (0.59) 1.55 (0.49) Week 24 - number 39 45 Change in mean value determined by LS (SE) - l 0.12 (0.09) 0.44 (0.09) Difference in mean value determined by LS compared to placebo (95% CI) 0.32 (from 0.10 to 0.54) The initial content of eosinophils in the blood < 300 cells / µl Baseline - no. 66 55 Average initial level (SD) - l 1.66 (0.62) 1.52 (0.56) Week 24 - number 65 52 Change in mean value determined by LS (SE) - l 0.00 (0.05) 0.13 (0.05) Difference in mean value determined by LS compared to placebo (95% CI) 0.13 (-0.02 to 0.28) Overall P-value of the interaction 0.174 The initial content of eosinophils in the blood ≥ 150 cells / µl Baseline - no. 69 81 Average initial level (SD) - l 1.68 (0.61) 1.56 (0.55) Week 24 - number 66 76 Change in mean value determined by LS (SE) - l 0.09 (0.06) 0.32 (0.06) Difference in mean value determined by LS compared to placebo (95% CI) 0.22 (from 0.06 to 0.38) The initial content of eosinophils in the blood < 150 cells / µl Baseline - no. 38 22 Average initial level (SD) - l 1.53 (0.61) 1.45 (0.45) Week 24 - number 38 21 Change in mean value determined by LS (SE) - l −0.08 (0.06) 0.16 (0.08) Difference in mean value determined by LS compared to placebo (95% CI) 0.24 (from 0.05 to 0.44) Overall P-value of the interaction 0.949

CI stands for confidence interval, FEV ₁ is forced expiratory volume in 1 second, LS is least squares, q2w is every 2 weeks, SD is standard deviation, and SE is standard error.

Improvements in FEV ₁ were rapid and sustained as early as week 2 (mean LS change was 0.15 L; 95% CI 0.04 to 0.26) and increased further by week 24 (P < 0.05 in all times) (FIG. 4C and Table 2). After 24 weeks, dupilumab provided an improvement in lung function, as measured by an increase in forced expiratory volume in one second (FEV ₁ ) of 220 ml (15 percent) in the general population (p = 0.0007) compared with 10 ml for placebo, and 320 ml (25 percent) versus 120 ml placebo in patients with eosinophil counts of 300 cells/µl or more (p=0.0049).

Other secondary and study outcomes

The phase 3 study included patients with steroid-dependent severe asthma, regardless of eosinophil levels or other biomarkers, and results showed improvements compared with placebo in lung function and exacerbations in patient subgroups: patients with baseline eosinophil counts greater than 300 cells/µl; more than 150 cells/µl and less than 150 cells/µl. Dupilumab has shown a consistent improvement in lung function in an asthma treatment program in patients with severe asthma who have difficulty with a decrease in their daily breathing ability.

ACQ-5 scores at week 24 indicated a significant improvement (P=0.002) in asthma control with dupilumab compared to placebo (difference in mean LS, change from baseline: −0.47 [95% CI from −0, 76 to −0.18]). With dupilumab, the mean least-squares improvement from baseline (−1.05) at week 24 was two minimum clinically significant differences of 0.5 for the ACQ-5 instrument.

Dupilumab treatment provided suppression of FeNO at the second week and was sustained over the 24-week treatment period (P < 0.001 vs. placebo at all time points; Figure 4D). The percentage of patients with FeNO < 25 ppb (upper limit of normal) (Table 6) increased from 43.6% at baseline to 84.4% in the dupilumab group, while there was no change in the placebo group (from 44.7% to 45 ,1%).

Table 6 Proportion of patients achieving FeNO suppression to < 25 ppb at baseline and week 24.

Placebo (N=107) 300 mg dupilumab q2w (N=103) Initial level, n 103 101 Median value (IQR) 29.0 (from 17.0 to 56.0) 28.0 (from 14.0 to 48.0) < 25 ppb - quantity (%) 46 (44.7) 44 (43.6) Week 24 91 90 Median value (IQR) 27.0 (from 16.0 to 45.0) 15.0 (from 11.0 to 21.0) Change from baseline, mean (SD) 0.3 (27.9) −17.3 (27.9) < 25 ppb - quantity (%) 41 (45.1) 76 (84.4) P-value versus placebo <0.001

FeNO is the exhaled nitric oxide fraction, IQR is the interquartile range, ppb is parts per billion, q2w is every 2 weeks, and SD is standard deviation.

Morning and evening daily asthma symptom scores in patients with oral corticosteroid-dependent severe asthma

Patients' asthma symptom scores were recorded as scores in an electronic diary in the morning for symptoms during the night (symptoms before noon) and in the evening (symptoms in the afternoon) for symptoms during the day, with a score of severity from 0 (easiest) to 4 (the heaviest). Changes from baseline in asthma symptom scores over a 24-week treatment period were analyzed using repeated measures mixed-effect models.

Mean a.m./p.m. symptom scores in the dupilumab and placebo groups, respectively, were 1.37/1.37 and 1.50/1.52 in the ITT population (n=210) and 1.45/1.49 and 1. 50/1.52 in patients who reduced their OCS use by 100% by week 24 (40.5%). In the dupilumab group, symptom scores improved rapidly (change in mean LS from baseline in symptom scores am/pm at week 2 ─0.18/─0.23; both P < 0.05 vs. placebo) with continued improvement at week 16 (─0.47/─0.47, both P<0.05 versus placebo) and maintained a positive effect until week 24 (Fig. 25A and Fig. 25C). Patients in the dupilumab arm who reduced their OCS by 100% by week 24 showed a similar response pattern with greater improvement in symptom scores (Figure 25B and Figure 25D). Overall, the most common treatment-related adverse events occurring in patients treated with dupilumab and placebo were eosinophilia (14% vs. 1%). Injection site reactions occurred in 9% of patients treated with dupilumab and 4% of patients treated with placebo.

Dupilumab provided rapid and sustained improvement in daily morning and evening asthma symptom scores in patients with OCS-related severe asthma despite OCS withdrawal. Improvement in symptom scores was greatest in patients who reduced OCS by 100% by week 24. Dupilumab was generally well tolerated.

Population: ITT; subgroup 100% reduction in OCS. Endpoints: change in mean value, determined by LS, from baseline in symptom scores a.m./p.m. over the treatment period. Treatment groups: dupilumab 300 mg q2w; placebo.

Asthma control and health-related quality of life

Asthma control was assessed by weekly electronic diary entry of the approved 5-item Asthma Control Questionnaire (ACQ-5), where a higher score (range 0-6) indicated less control. Health-related quality of life (HRQoL) was assessed using a self-administered 7-item Asthma Quality of Life Questionnaire (AQLQ), where higher overall scores (range 0-7) indicated better HRQoL. Changes from baseline in ACQ-5 and AQLQ scores over the 24-week treatment period were analyzed using repeated measures mixed effect models.

In the dupilumab and placebo groups, respectively, mean baseline ACQ-5 scores were 2.42 and 2.58, and mean baseline AQLQ scores were 4.38 and 4.31. In the dupilumab group, asthma control improved rapidly (week 2, mean LS change from baseline in ACQ-5 score, 0.57; P=0.002 vs. placebo), improved further at week 12 (1.01; P =0.001 vs. placebo) and remained stable until week 24 (1.05; P=0.002 vs. placebo) (FIG. 26A). Patients treated with dupilumab experienced an improvement in mean LS from baseline in AQLQ score of 0.76 at week 12 (P = 0.14 vs. placebo), which further improved to 0.89 at week 24 ( P=0.008 vs. placebo) (FIG. 26B). Overall, the most common treatment-related adverse events occurring in patients treated with dupilumab and placebo were eosinophilia (14% vs. 1%). Injection site reactions occurred in 9% of patients treated with dupilumab and 4% of patients treated with placebo.

The addition of dupilumab compared with placebo provided a significant improvement in asthma control and improvement in HRQoL in patients with OCS-related severe asthma. Improvement in asthma control occurred as early as week 2 and was maintained for 24 weeks. Dupilumab was generally well tolerated.

Population: I.T.T. Endpoints: Change in mean LS-determined from baseline ACQ-5 at weeks 2, 12, and 24; change in mean value determined by LS from baseline AQLQ at weeks 12 and 24; safety during the treatment period. Treatment groups: dupilumab 300 mg q2w; placebo.

Safety

The incidence of TEAE was similar across all treatment groups (62.1% versus 64.5% for dupilumab versus placebo) in the safety population. TEAE according to the Medical Dictionary for Regulatory Practice (MedDRA) Preferred Terms, most common in ≥ 5% of patients treated with dupilumab compared with placebo had upper respiratory tract viral infections (8.7% versus 17.8% ), bronchitis (6.8% vs. 5.6%), sinusitis (6.8% vs. 3.7%), influenza (2.9% vs. 5.6%), injection site reactions (8.7% relative to 3.7%) and laboratory values of eosinophilia (grouped as the preferred terms "increased eosinophils" and "eosinophilia") (13.6% relative to 0.9%). According to the study protocol, all cases of eosinophils > 3000 cells/μl during treatment were to be reported as AE and occurred in 12.6% of patients treated with dupilumab, compared with 0.9% in the placebo group. The reported TEAE eosinophilias were purely laboratory findings with no clinical sequelae or associated AEs.

Serious TEAEs were reported in 9 (8.7%) patients treated with dupilumab and 6 (5.6%) treated with placebo; serious TEAEs were not related to the investigational medicinal product. There were no deaths in this study. Treatment-induced humoral immune responses to the drug were observed in 5 patients in each arm (dupilumab 5.0%; placebo 4.7%) and did not significantly affect efficacy or safety.

Table 7. Changes in FEV ₁ and inflammatory biomarkers at weeks 4 and 24 in patients treated with dupilumab compared with placebo.

PBO (N=107) 300 mg DPL q2w (N=103) FEV ₁ before bronchodilator administration BL, l, mean value (SD) 1.63 (0.61) 1.53 (0.53) Change from BL at week 4, mean value determined by LS (SE) 0.04 (0.04) 0.18 (0.04)* Change from BL at week 24, mean value determined by LS (SE) 0.01 (0.05) 0.22 (0.05)*** FeNO BL, ppb, mean (SD) 39.6 (34.1) 35.6 (28.3) Change from BL at week 4, ppb, mean (SD) −0.7 (25.4) −14.6 (23.0) Change from BL at week 24, ppb, mean (SD) 0.3 (27.9) −17.3 (27.9) Percent change in mean from BL at week 4 (SD) 8.05 (74.96) −28.19 (38.99)*** Percent change in mean from BL at week 24 (SD) 11.07 (51.93) −30.36 (46.00)*** Eotaxin-3 BL, PG/ML, Mean (SD) 50.62 (40.75) 47.86 (52.18) Percent change in mean from BL at week 4 (SD) 64.68 (231.22) −1.46 (176.66)*** Percent change in mean from BL at week 24 (SD) 57.13 (187.87) 4.90 (181.84)*** Total IgE BL, IU/ML, Mean (SD) 426.62 (881.22) 434.65 (654.54) Percent change in mean from BL at week 4 (SD) −0.02 (86.60) −19.97 (18.01)*** Percent change in mean from BL at week 24 (SD) 7.98 (92.76) −56.21 (19.91)*** Periostin - Shino test BL, PG/ML, Mean (SD) 69.10 (24.96) 78.88 (34.72) Percent change in mean from BL at week 4 (SD) 3.50 (20.97) −14.41 (25.79)*** Percent change in mean from BL at week 24 (SD) 8.60 (36.81) −19.03 (25.35)*** TARC BL, PG/ML, Mean (SD) 428.03 (663.07) 369.81 (298.11) Percent change in mean from BL at week 4 (SD) 22.46 (121.05) −25.03 (54.16)*** Percent change in mean from BL at week 24 (SD) 12.63 (65.52) −22.96 (44.94)***

*P < 0.05, **P < 0.01, ***P < 0.001 relative to placebo.

CI - confidence interval, SE - standard error, SD - standard deviation, FEV ₁ - forced expiratory volume in 1 second, FeNO - nitric oxide fraction in exhaled air, TARC - chemokine regulated by thymus and activation.

Ways

Study design and supervision

This phase 3, multinational, randomized, double-blind, placebo-controlled study evaluated the efficacy and safety of dupilumab in patients with oral glucocorticoid-dependent severe asthma. Patients completed an 8- to 10-week oral glucocorticoid dose optimization period followed by 1:1 randomization to receive dupilumab or placebo over a 24-week treatment period. This treatment period consisted of a 4-week induction period during which the optimized dose of oral glucocorticoid was continued; A 16-week oral glucocorticoid taper period (weeks 4-20) during which the dose of glucocorticoids was tapered every 4 weeks according to a predefined protocol algorithm; A 4-week maintenance period during which patients remained on the glucocorticoid dose established at week 20; and a 12-week post-treatment evaluation period. Eligible patients who completed treatment were eligible for a long-term, open-label extension study.

The study was conducted in accordance with the Declaration of Helsinki, the guidelines of the International Conference on Harmonization of Good Clinical Practice and applicable regulatory requirements. An independent Data and Safety Monitoring Committee blindly monitored patient safety data. A local institutional review board or ethics committee at each study site oversaw trial performance and documentation. All patients gave written informed consent before taking part in the trial.

Patients

Patients ≥ 12 years of age with physician-diagnosed asthma for ≥ 12 months were eligible, based on the 2014 Global Asthma Initiative Guidelines. Patients must have taken regular systemic glucocorticoids for the previous 6 months (5 to 35 mg/day of prednisone or prednisolone or equivalent) in the 4 weeks prior to screening, as well as high doses of inhaled glucocorticoid (total daily dose of fluticasone propionate or equivalent > 500 mcg) in combination with up to two control drugs (eg, long-acting β2-agonist or leukotriene receptor antagonist) for ≥ 3 months. Eligible patients were to have a forced expiratory volume in 1 second (FEV ₁ ) before bronchodilator administration ≤ 80% of predicted normal (≤ 90% for adolescents), reversibility of 17 FEV ₁ ≥ 12% and 200 mL, or documented airway hyperresponsiveness within 12 months prior to Screening Visit 1. Patients were recruited without minimum baseline requirements for blood or sputum eosinophils or any other type 2 biomarkers (eg, FeNO or IgE). Key exclusion criteria included lung disease other than asthma, worsening asthma requiring emergency treatment or hospitalization within 4 weeks of Visit 1, and current smokers or smokers who had quit smoking within 6 months prior to screening or had a history of smoking > 10 pack years

Treatments and procedures

Patients were randomized (1:1) to receive dupilumab 300 mg subcutaneously (following a loading dose of 600 mg on day 1) as add-on therapy or matched placebo every 2 weeks (q2w). Randomization was done using interactive voice/digital response technology and patients were stratified according to optimized oral glucocorticoid dose (≤ 10 mg/day or > 10 mg/day prednisone/prednisolone) and country. Patients using other oral glucocorticoids were switched to a clinically comparable dose of prednisone or prednisolone during the screening period.

The optimized dose of oral glucocorticoid was defined as the lowest dose that the patient could tolerate without an increase of ≥ 0.5 score on the 5-item Asthma Control Questionnaire (ACQ-5), severe exacerbation, or any clinically significant event requiring dose adjustment of oral glucocorticoid . During the dose taper phase, the dose of oral glucocorticoid was reduced every 4 weeks to minimize the risk of clinically significant events and the effects of the previous dose. Dose adjustment was not allowed after week 20 except for safety reasons. Background asthma control medications were continued at a stable dose, and short-acting β2-agonists were allowed as needed for asthma symptoms.

Endpoints

The primary efficacy endpoint was the percentage reduction in oral glucocorticoid dose from baseline by week 24 while maintaining asthma control. A patient was considered to be in maintenance asthma control between weeks 20 and 24 if no clinically significant event (based on the judgment of the investigator) required adjustment of the dose of oral glucocorticoid. For patients who experienced an exacerbation, the final dose of oral glucocorticoid was considered to be one dose higher than that which they received during the exacerbation.

The key secondary efficacy endpoints assessed in patients maintaining asthma control were the proportion of patients achieving ≥ 50% reduction in oral glucocorticoid dose from baseline and the proportion of patients achieving a reduction in oral glucocorticoid dose to < 5 mg/day. Other secondary endpoints included absolute dose reduction of oral glucocorticoid, the proportion of patients who achieved the maximum possible dose reduction of oral glucocorticoid, and the proportion of patients who no longer required oral glucocorticoids.

Additional efficacy endpoints included the annualized rate of severe exacerbations during the treatment period (defined as the need for hospitalization, an emergency department visit, or treatment for ≥ 3 days with at least 2 times the current dose of systemic glucocorticoids); absolute change from baseline FEV ₁ to bronchodilator administration at weeks 2, 4, 8, 12, 16, 20 and 24; and change from baseline in ACQ-5 at week 24.

The study endpoint of absolute change from baseline FeNO (ppb) was assessed using the NIOX instrument (Aerocrine AB, Solna, Sweden) at weeks 2, 4, 8, 12, 16, 20 and 24.

Statistical analysis

It was found that 90 randomized patients per treatment group would give the study a 94% power (2-sample test at α=0.05) to reveal a treatment difference of 27% in the daily dose of glucocorticoid 18, provided that the total standard deviation is 50%.

The primary endpoint was analyzed using an analysis of covariance (ANCOVA) model. The model included percentage reduction in oral glucocorticoid dose at week 24 as dependent variable and treatment group, baseline-optimized oral glucocorticoid dose, regions (pooled countries), and subgroups based on baseline eosinophil counts (≥ 150 cells/μL, < 150 cells/μL ) as a covariate. Difference in treatment was tested at a 2-sample significance level of α=0.05. For patients who discontinued the study or were missing oral glucocorticoid dose data at week 24 (2 patients in the dupilumab group and 1 in the placebo group), the primary approach to handling missing data was the Multiple Reconstruction Pattern Combination Model (PMM by MI) .

Key secondary and other combined secondary endpoints were analyzed using logistic regression models. The annualized frequency of severe exacerbation events during the 24-week treatment period was analyzed using a negative binomial regression model. A repeated measures mixed-effects model approach was used to analyze changes from baseline FEV ₁ to bronchodilator administration at various time points during the 24-week treatment period and changes from baseline to the 5-item Asthma Control Questionnaire (ACQ). -5) in week 24.

Efficacy analyzes were performed on an intent-to-treat (ITT) population, defined as all randomized patients analyzed for intent-to-treat, regardless of treatment received. Primary and key secondary endpoints, FEV ₁ and severe asthma exacerbation were also analyzed in subgroups of patients defined by baseline blood eosinophil levels (≥ 300 cells/μL, < 300 cells/μL, ≥ 150 cells/μL, and < 150 cells /µl). The safety population included all patients who received ≥ 1 dose or partial dose of investigational treatment analyzed according to treatment received.

All analyzes were performed using SAS software, version 9.4 (SAS Institute).

Conclusion

This study demonstrated that dupilumab as add-on therapy provided a significant reduction in oral glucocorticoid use in patients with oral glucocorticoid-dependent severe asthma, a 59.3% reduction in severe asthma exacerbations, and an improvement in FEV ₁ per 0.22 L in the general population with a reduction of 71% of exacerbations and improvement of 0.32 l FEV ₁ in patients with "eosinophilia" with an initial blood eosinophil count ≥ 300 cells / μl. Dupilumab treatment also provided improved asthma control and reduced levels of FeNO, a marker of type 2 airway inflammation.

The addition of dupilumab 300 mg every 2 weeks (q2w) (compared to placebo) provided a significant reduction in oral corticosteroid (OCS) use at week 24 (mean least squares [LS] was 70.1% versus 41.9% , median value 100% vs. 50%) while reducing the frequency of severe asthma exacerbation during the 24-week treatment period (59%) and improving forced expiratory volume in 1 second (FEV1) at week 24 (the difference in the means determined by LS is 0.22 L) and was generally well tolerated by patients with OCS-related severe asthma.

Dupilumab is the first biologic to demonstrate positive efficacy on multiple outcome measures for asthma in the general study population, regardless of baseline blood eosinophil counts (i.e., ≥ 300, < 300, ≥ 150, and < 150 cells/mcL). Indeed, 28.6% of the included patients had a baseline blood eosinophil count < 150 cells/µl. In this subgroup, 75% of patients treated with dupilumab had oral glucocorticoid doses reduced by 50%, and oral glucocorticoid doses were reduced to <5 mg/day in 62% of patients. These data are inconsistent with previous studies with monoclonal antibodies to interleukin-5, including mepolizumab and benralizumab, which showed treatment effect only in patients with high baseline blood eosinophil counts.

In this study, patients treated with placebo also experienced a 41.9% reduction in oral glucocorticoid dependence. Better adherence to drug regimens in the clinical study setting may have contributed to this observation. However, towards the end of the study, these placebo-treated patients experienced a moderate deterioration in lung function (FEV ₁ ), further highlighting the need for treatment that improves lung function in patients with oral glucocorticoid-dependent severe asthma. The ability of dupilumab to increase lung function as markedly as it did in this study, even despite glucocorticoid withdrawal, indicates that it appears to inhibit key factors in lung inflammation that lead to decreased lung function.

Dupilumab reduced FeNO levels in the setting of significant oral glucocorticoid withdrawal in the study population with persistent type 2 inflammation (defined by elevated FeNO) despite systemic glucocorticoid use.

Dupilumab provided an observed mean 74% reduction in oral glucocorticoid dose (observed mean 100%) in a larger population with no requirement for a minimum baseline blood eosinophil count. Without wishing to be bound by scientific theory, these data indicate that dupilumab, with its dual blockade of the interleukin-4 and interleukin-13 signaling pathways via blockade of the interleukin-4 receptor alpha, inhibits type 2 inflammation more extensively than targeting eosinophils alone. While interleukin-4 plays a central role in the differentiation and proliferation of T helper 2 cells by inducing cytokine production and IgE synthesis, interleukin-13 plays a key role in the pathological features of the disease, such as goblet cell hyperplasia, mucus production, smooth cell contractility. muscles and airway hypersensitivity.

In patients with glucocorticoid-dependent severe asthma, dupilumab was generally well tolerated and the safety profile was consistent with previous studies in asthma and other indications such as eosinophilic esophagitis, nasal polyposis, and atopic dermatitis. Patients treated with dupilumab experienced a greater mean transient increase in blood eosinophils from baseline compared with placebo, with an increase in the proportion of patients (12.6%) with eosinophils >3000 cells/μl. Patients with transient elevations in blood eosinophils had no associated clinical AE or sequelae. The increase in blood eosinophils is consistent with the hypothesis that dupilumab blocks the function of interleukin-4 and interleukin-13 in terms of survival, activation and recruitment of eosinophils in tissue, but not return from the bone marrow, resulting in a transient increase in circulating eosinophils. Since glucocorticoids suppress circulating eosinophils, the greater reduction in oral glucocorticoid in the dupilumab group may also contribute to the increase in eosinophils. No treatment-related AE conjunctivitis was observed between the dupilumab and placebo groups, in contrast to studies of dupilumab in atopic dermatitis.

In conclusion, dupilumab adjunctive therapy provided a significant reduction in the need for oral glucocorticoids, while reducing severe exacerbations and improving lung function (FEV ₁ ) in patients with glucocorticoid-dependent severe asthma, regardless of baseline blood eosinophil levels, and overall good endured.

Example 2 Phase III trial of the QUEST study (NCT02414854)

Ways

Patients with asthma ≥12 years of age, with moderate to severe asthma uncontrolled by ICS and one or two control agents, were randomized 2:1 to receive dupilumab 200 or 300 mg subcutaneously every 2 weeks (q2w) or comparable placebo for 52 weeks in a phase 3, double-blind, placebo-controlled trial (NCT02414854). The primary endpoints were the annual rate of severe asthma exacerbations and the absolute change from baseline to week 12 in forced expiratory volume in 1 second (FEV ₁ ) before bronchodilator administration in the general study population. Secondary endpoints included exacerbations and FEV ₁ in patients with ≥ 300 eosinophils/µL. Asthma control and the safety of dupilumab were also evaluated. The combined primary endpoints were the annualized rate of severe exacerbation at 52 weeks and the change in FEV ₁ (L) from baseline to week 12.

Specific details of the study are described below. This randomized, double-blind, placebo-controlled, parallel-group trial evaluated the efficacy of dupilumab in patients with moderate to severe uncontrolled asthma. Patients completed a screening period of 4 ± 1 weeks followed by randomization to dupilumab and placebo of a comparable volume, a 52-week randomized treatment period, and a 12-week post-treatment follow-up period (see Fig. 7).

Patients

Patients ≥ 12 years of age with a physician-diagnosed 2014 Global Asthma Initiative Guidelines for persistent asthma for ≥ 12 months were eligible if they met the following key criteria: Current treatment with an inhaled glucocorticoid at a moderate to high dose (total daily dose fluticasone propionate or equivalent > 500 mcg) plus no more than two additional controller drugs (eg, long-acting _β2 -agonist or leukotriene receptor antagonist); forced expiratory volume in 1 second (FEV ₁ ) before the introduction of a bronchodilator (BD) ≤ 80% of the predicted norm (≤ 90% for people aged 12 to 17 years); reversibility FEV ₁ ≥ 12% and 200 ml; 5-item Asthma Control Questionnaire (ACQ-5) score ≥ 1.5; worsening asthma in the previous year that required hospitalization, emergency care, or treatment with systemic glucocorticoids for ≥ 3 days. Patients were recruited regardless of baseline levels of eosinophils or type 2 biomarkers in the blood. (See Fig. 8).

Treatments and procedures

Patients were randomized (2:2:1:1) to receive 52 weeks of add-on therapy with 200 mg (loading dose 400 mg) or 300 mg dupilumab (loading dose 600 mg) every 2 weeks (q2w) or a comparable volume of placebo for each active dose (supplied in pre-filled syringes, 1.14 ml for dupilumab 200 mg and 2.0 ml for dupilumab 300 mg). Randomization was performed using interactive voice/digital response technology and stratified by age (< 18 years, ≥ 18 years), peripheral blood eosinophil count (< 300 cells/μL, ≥ 300 cells/μL) at screening, dose level inhaled glucocorticoid (medium/high) and country. Asthma control background medications continued at a stable dose throughout the study and were recorded daily by patients in an electronic diary. Inhaled glucocorticoids, long-acting β2 _- agonists, long-acting muscarinic receptor antagonists, leukotriene receptor antagonists, and methylxanthines have been approved. Throughout the study, patients were allowed to use short-acting β ₂ -adrenergic receptor agonists necessary to relieve symptoms. Type 2 biomarkers were measured; biomarkers included blood eosinophils, serum FeNO, IgE, plasma periostin, TARC, and eotaxin-3.

Endpoints

The primary efficacy endpoints were the annualized rate of severe exacerbation events during the 52-week treatment period and the absolute change from baseline in FEV ₁ to BD at week 12 in the overall study population. These endpoints were also included as secondary study endpoints for individuals with blood eosinophil counts ≥ 300 eosinophils/µl. Additional secondary endpoints of the study are summarized in Table 8. Severe asthma exacerbation was defined as a worsening of asthma requiring treatment for ≥ 3 days with systemic glucocorticoids or hospitalization or an emergency room visit requiring systemic glucocorticoids. Safety and tolerability were recorded according to the frequency of treatment-related adverse events (TEAE) and serious TEAE.

Table 8. Summary of study outcomes according to the tiered testing procedure.

Final indicators Time frame Primary efficacy endpoints Annualized frequency of severe asthma exacerbations 52 weeks Absolute change from baseline FEV ₁ to bronchodilator administration Week 12 Secondary endpoints of effectiveness. Percent change from baseline FEV ₁ before bronchodilator administration Week 12 Annualized frequency of severe asthma exacerbations in patients with ≥ 150 eosinophils/mcL 52 weeks Absolute change from baseline FEV ₁ to bronchodilator administration in patients with ≥ 150 eosinophils/mcL Week 12 Annualized rate of severe asthma exacerbations in patients with ≥ 300 eosinophils/mcL 52 weeks Absolute change from baseline FEV ₁ to bronchodilator administration in patients with ≥ 300 eosinophils/mcL Week 12 Annualized rate of severe asthma exacerbations in patients with < 300 eosinophils/mcL 52 weeks Year-on-year frequency of severe asthma exacerbations in patients on high-dose inhaled glucocorticoids 52 weeks Absolute change from baseline in FEV ₁ to bronchodilator administration in patients on high-dose long-acting inhaled glucocorticoids/ _β2 -agonists Week 12 Change from baseline in total AQLQ [S] Week 24 Change from baseline in total AQLQ [S] in patients with ≥ 300 eosinophils/μL Week 24 Change from baseline in ACQ-5 score Week 24 Annualized frequency of severe asthma exacerbations resulting in hospitalization or emergency department visit 52 weeks Absolute change from baseline FEV ₁ to bronchodilator administration in patients with < 300 eosinophils/mcL Week 12

ACQ-5 stands for the 5-item version of the Asthma Control Questionnaire and AQLQ(S) stands for the Asthma Quality of Life Questionnaire (Standardized Version).

Statistical analysis

It was found that a sample size of approximately 1638 patients would give the study 99% power (2-sample test at α=0.05) to detect a 55% reduction in the relative risk of the annualized rate of severe exacerbations (i.e. the annualized rate of calculus of 0.6 and 0.27 for the placebo and dupilumab groups, respectively). This sample size was also expected to provide 98% power to detect a treatment difference in FEV ₁ to BD change from baseline of 0.15 L at week 12. Efficacy analyzes were performed on the Treatment Intended Treatment (ITT) population, defined as all randomized patients analyzed according to the prescribed treatment, regardless of whether they received treatment. The annualized frequency of severe exacerbations was analyzed using a negative binomial regression model including four treatment groups, age, region, baseline eosinophil levels, baseline dose of inhaled glucocorticoid, and previous exacerbations 1 year prior as covariates. Change from baseline in continuous endpoints such as FEV ₁ and patient outcomes were analyzed using a repeated measures mixed effects model (MMRM) including treatment, age, baseline eosinophil levels, baseline inhaled glucocorticoid dose level, visit, interaction with treatment factor effect versus visit, baseline and interaction with baseline factor effect versus visit as covariates. Gender and baseline height were included as covariates only in models for spirometry parameters.

results

Baseline demographics and clinical characteristics of the ITT population are shown in Table 4 and were generally comparable across all four treatment groups (Table 10). In 1902 patients, dupilumab 200/300 mg q2w compared with placebo provided a 48%/46% year-on-year reduction in severe exacerbations over a 52-week treatment period (both P < 0.0001) (Figure 9A). Improvement in FEV ₁ was observed at week 12 (difference in means determined by LS versus placebo 0.14 L/0.13 L; both P < 0.0001) in the general population.

Analyzes in predefined subgroups based on baseline blood eosinophils showed a significant reduction in the frequency of exacerbations (P < 0.001) with dupilumab 200 and 300 mg compared with a comparable volume placebo in patients with ≥ 300 eosinophils/mcL (65.8% reduction and 67.4% compared with placebo) and patients with ≥ 150 eosinophils/mcL (reduction of 55.8% and 59.8% compared with placebo). There were consistent trends but no significance for exacerbation endpoints and FEV ₁ in patients with <300 eosinophils/μl. Analyzes in predefined subgroups based on FeNO levels showed a similar effect (P < 0.001). (See Fig. 9B and Table 9)

Table 9. Summary of primary efficacy endpoint and secondary endpoints.

Randomized treatment group in the general population Placebo (N=317) 200 mg dupilumab q2w (N=631) Placebo (N=321) 300 mg dupilumab q2w (N=633) Adjusted annualized frequency of severe asthma exacerbations Estimate (95% CI) 0.871 (from 0.724 to 1.048) 0.456 (from 0.389 to 0.534) 0.970 (from 0.810 to 1.160) 0.524 (0.450 to 0.611) Relative risk versus comparable placebo† (95% CI) - 0.523 (0.413 to 0.662) - 0.540 (0.430 to 0.680) P-value versus comparable placebo† <0.001 <0.001 Baseline mean (SD) FEV ₁ before bronchodilator administration - l 1.76 (0.61) 1.78 (0.62) 1.75 (0.57) 1.78 (0.60) Change from baseline FEV ₁ at week 12 Change in mean value determined by LS (SE) - l 0.18 (0.02) 0.32 (0.02) 0.21 (0.02) 0.34 (0.02) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ - 0.14 (from 0.08 to 0.19) - 0.13 (from 0.08 to 0.18) P-value versus comparable placebo‡ <0.001 <0.001 Percent change from baseline FEV ₁ at week 12 Mean value determined by LS (SE) 12.11 (1.56) 21.34 (1.13) 13.67 (1.56) 23.08 (1.13) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ - 9.23 (from 5.54 to 12.92) - 9.41 (from 5.74 to 13.07) P-value versus comparable placebo‡ <0.001 <0.001 Adjusted annualized rate of severe asthma exacerbations in patients with ≥ 300 eosinophils/mcL N=148 N=264 N=142 N=277 Estimate (95% CI) 1.081 (0.846 to 1.382) 0.370 (0.289 to 0.475) 1.236 (0.972 to 1.571) 0.403 (from 0.317 to 0.512) Relative risk versus comparable placebo† (95% CI) - 0.342 (from 0.244 to 0.480) - 0.326 (from 0.234 to 0.454) P-value versus comparable placebo† <0.001 <0.001 Change from baseline FEV ₁ in patients with ≥ 300 eosinophils/mcL at week 12 N=144 N=256 N=139 N=266 Change in mean value determined by LS (SE) 0.21 (0.03) 0.43 (0.03) 0.22 (0.03) 0.47 (0.02) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ - 0.21 (from 0.13 to 0.29) - 0.24 (from 0.16 to 0.32) P-value versus comparable placebo‡ <0.001 <0.001 Adjusted annualized rate of severe asthma exacerbations in patients with ≥ 150 eosinophils/mcL N=232 N=437 N=237 N=452 Estimate (95% CI) 1.007 (0.814 to 1.245) 0.445 (from 0.368 to 0.538) 1.081 (0.879 to 1.329) 0.434 (from 0.359 to 0.525) Relative risk versus comparable placebo† - 0.442 (from 0.337 to 0.581) - 0.402 (from 0.307 to 0.526) P-value versus comparable placebo† <0.001 <0.001 Change from baseline FEV ₁ in patients with ≥ 150 eosinophils/mcL at week 12 N=224 N=425 N=229 N=434 Change in mean value determined by LS (SE) 0.18 (0.03) 0.36 (0.02) 0.22 (0.03) 0.37 (0.02) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ 0.17 (from 0.11 to 0.23) 0.15 (from 0.09 to 0.21) P-value versus comparable placebo‡ <0.001 <0.001

In the general study population, 200 and 300 mg q2w provided an improvement in FEV ₁ to BD at week 12 of 0.32 L and 0.34 L, respectively (difference of 0.14 and 0.13 L compared with comparable placebo, P < 0.001) (Fig. 10A). In patients with ≥ 300 eosinophils/µL, FEV improvements were greater: dupilumab provided an improvement in FEV ₁ at week 12 of 0.43 L and 0.47 L, respectively (difference of 0.21 and 0.24 L compared with comparable placebo, P < 0.001). (See Figure 10B.) Improvement in FEV ₁ was rapid (with significant differences from placebo evident at first assessment at week 2 for both regimens) and was maintained throughout the 52-week treatment period (P < 0.001 for both regimens at week 52). In addition, slope analysis for FEV ₁ after bronchodilator administration between weeks 8 and 52 showed a placebo loss of lung function of 0.04 L/yr with no loss at any of the dupilumab doses (P < 0.05).

Improvements in FEV ₁ at week 12 (P < 0.05) with both dosing regimens were more significant in the subgroup of patients with higher baseline FeNO levels (0.19 and 0.12 L for FeNO ≥ 25 to 50; 0.30 and 0.39 L for FeNO ≥ 50 ppb). (See Fig. 10C and Table 8.)

In addition, dupilumab 200 and 300 mg provided a significant improvement in the percentage change in FEV ₁ before bronchodilator administration from baseline at week 12 compared with placebo: 21.34% vs. 12.11% and 23.08% vs. 13.67%, respectively. (P < 0.001). The rate of severe exacerbation events leading to hospitalization or an emergency department visit during the 52-week treatment period was 0.035 vs. 0.065 (P = 0.004) when comparing the combination of patients treated with dupilumab with the combination of patients treated with placebo. This resulted in a 46.8% relative risk reduction for dupilumab compared to placebo. (See table 9.)

Dupilumab provided a significant improvement in ACQ-5 as early as week 2, and the effect was maintained throughout the course of treatment (P < 0.01). Similarly, scores on the standardized version of the Asthma Quality of Life Questionnaire, scores for asthma symptoms a.m. and p.m., and peak a.m. and p.m. expiratory flow improved at week 24 and week 52. (See Table 9. )

Patients treated with dupilumab showed greater reductions from baseline in FeNO, total IgE, periostin, eotaxin-3, and TARC over the course of treatment compared with placebo (Table 13). In both treatment groups, a transient increase in blood eosinophils was observed, which decreased to near baseline levels by week 52.

To better understand the effect of dupilumab in patients with evidence of type 2 inflammation, analyzes were performed to assess the relationship of efficacy biomarkers. Each biomarker was tested in a spline model with no penalty for interactions with the biomarker factor effect versus treatment for exacerbations and FEV _1. In these analyses, interactions for eosinophils and FeNO were significant (P < 0.05) when the outcome was exacerbations, while eosinophils, FeNO, periostin, ECP, IgE, and eotaxin-3 were significant for FEV ₁ at week 12 (Table 11). The effect of dupilumab on exacerbations was similar for above and below median IgE levels at baseline (167 IU/mL) and more significant for improvement in FEV ₁ at above median IgE levels.

Patients treated with dupilumab with baseline blood eosinophils ≥ 150 cells/μL and FeNO ≥ 25 ppb (type 2 high) had a greater treatment benefit compared to placebo in terms of both reducing the rate of severe exacerbation and FEV improvements ₁ . (See Fig. 11A and Fig. 11B.) In patients with baseline eosinophils < 150 cells/μl and FeNO < 25 ppb, no treatment effect was observed (type 2 - low). However, patients treated with dupilumab with baseline blood eosinophils < 150 cells/µl and FeNO ≥ 25 ppb or ≥ 150 cells/µl and FeNO < 25 ppb experienced a numerical reduction in the rate of severe exacerbation.

The most common adverse event in the dupilumab-treated groups compared with placebo was injection site reactions (15%/18% versus 5%/10%, respectively). In contrast to studies with dupilumab in atopic dermatitis, the incidence of conjunctivitis was similar between dupilumab and placebo.

Table 10. Baseline demographics and clinical characteristics (ITT population).

placebo Dupilumab 200 mg q2w placebo Dupilumab 300 mg q2w General population N=317 N=631 N=321 N=633 N=1902 Mean (SD) age - years 48.2 (15.6) 47.9 (15.3) 48.2 (14.7) 47.7 (15.6) 47.9 (15.3) < 18 years - number of patients (%) 21 (6.6) 34 (5.4) 18 (5.6) 34 (5.4) 107 (5.6) Female gender - number of patients (%) 198 (62.5) 387 (61.3) 218 (67.9) 394 (62.2) 1197 (62.9) Average value (SD) BMI - kg/ ^m2 29.76 (7.25) 29.05 (6.52) 29.21 (6.95) 29.07 (6.68) 29.20 (6.77) Mean value (SD) FEV ₁ before the introduction of a bronchodilator - l 1.76 (0.61) 1.78 (0.62) 1.75 (0.57) 1.78 (0.60) 1.78 (0.60) Mean (SD) FEV ₁ before bronchodilator administration - predicted % 58.43 (13.22) 58.38 (13.52) 58.35 (13.87) 58.51 (13.52) 58.43 (13.52) Mean value (SD) of FEV reversibility ₁ - % 25.06 (18.76) 27.39 (22.79) 26.45 (17.65) 25.73 (23.79) 26.29 (21.73) Mean value (SD) of exacerbations in the last year - no. 2.07 (1.58) 2.07 (2.66) 2.31 (2.07) 2.02 (1.86) 2.09 (2.15) High dose inhaled glucocorticoid/LABA use - no. of patients (%) 172 (54.3) 317 (50.2) 167 (52.0) 323 (51.0) 979 (51.5) Mean (SD) of ACQ-5† 2.71 (0.73) 2.76 (0.80) 2.77 (0.77) 2.77 (0.76) 2.76 (0.77) Mean (SD) of total AQLQ‡ 4.26 (1.02) 4.31 (1.08) 4.30 (1.03) 4.28 (1.05) 4.29 (1.05) Mean (SD) AM Asthma Symptom Score§ 1.16 (0.81) 1.14 (0.85) 1.12 (0.84) 1.12 (0.87) 1.14 (0.85) Mean (SD) Asthma Symptom Score in the Afternoon§ 1.27 (0.82) 1.26 (0.85) 1.23 (0.82) 1.27 (0.84) 1.26 (0.84) Current atopic/allergic condition - no. of patients (%) 266 (83.9) 509 (80.7) 266 (82.9) 524 (82.8) 1565 (82.3) Atopic dermatitis 35 (11.0) 61 (9.7) 38 (11.8) 62 (9.8) 196 (10.3) allergic rhinitis 221 (69.7) 421 (66.7) 225 (70.1) 438 (69.2) 1305 (68.6) Nasal polyposis and/or chronic rhinosinusitis 63 (19.9) 126 (20.0) 70 (21.8) 123 (19.4) 382 (20.1) Former smoker - no. of patients (%) 59 (18.6) 126 (20.0) 67 (20.9) 116 (18.3) 368 (19.3) Mean (SD) pack-years - no. 3.96 (2.81) 3.89 (2.69) 4.07 (3.12) 4.15 (3.04) 4.02 (2.89) Biomarker levels Mean value (SD) of the content of eosinophils in the blood - cells/µl 370 (338) 349 (345) 391 (419) 351 (369) 360 (366) Median value (min - max) of the content of eosinophils in the blood - cells / μl 270 (0-2200) 250 (0-3610) 265 (0-3580) 250 (0-4330) 255 (0-4330) Mean value (SD) FeNO - ppb 34.47 (28.54) 34.45 (34.91) 38.39 (38.00) 34.01 (29.74) 34.97 (32.85) Median value (min - max) FeNO - ppb 26.00 (3.0-197.0) 23.00 (3.0-387.0) 27.00 (5.0-351.0) 24.00 (4.0-202.0) 25.00 (3.0-387.0) Mean value (SD) of total IgE - IU / ml 393.90 (624.70) 460.96 (817.75) 448.47 (796.66) 415.08 (701.40) 432.40 (746.66) Median value (min - max) of total IgE - IU / ml 174.50
(1.0-5000.0) 154.00
(1.0-5000.0) 178.50
(3.0-5000.0) 174.00
(1.0-5000.0) 167.00
(1.0-5000.0) Mean (SD) TARC - pg/ml 377.88 (288.22) 394.12 (457.89) 398.00 (344.16) 364.35 (295.58) 382.22 (364.25) Median value (min - max) TARC - pg / ml 296.00 (from 33.1 to 1970.0) 314.50 (from 15.6 to 8600.0) 300.00 (from 34.0 to 3210.0) 295.00 (from 15.6 to 3170.0) 302.00 (from 15.6 to 8600.0) Mean value (SD) periostin - ng/ml 79.62 (36.58) 79.88 (39.18) 80.94 (40.73) 78.49 (37.90) 79.55 (38.58) Median value (min - max) periostin - ng / ml 71.70 (from 27.8 to 244.9) 70.60 (from 20.5 to 368.2) 71.00 (from 25.1 to 312.8) 69.70 (from 19.2 to 298.5) 70.60 (from 19.2 to 368.2) Mean value (SD) of eotaxin-3 - pg/ml 52.11 (86.35) 78.30 (340.04) 50.89 (57.85) 69.53 (481.53) 66.36 (342.53) Median value (min - max) of eotaxin-3 - pg / ml 36.50 (from 2.0 to 1180.0) 39.15 (from 2.0 to 6430.0) 37.45 (from 2.0 to 723.0) 38.30 (from 2.0 to 12000.0) 38.20 (from 2.0 to 12000.0)

ACQ-5 is the 5-item asthma control questionnaire, AQLQ(S) is the asthma quality of life questionnaire (standardized version), BMI is body mass index, FeNO is nitric oxide fraction in exhaled air, FEV ₁ is forced volume exhalation per second, LABA - long acting β ₂ agonist, min - max - minimum to maximum, ppb - parts per billion, q2w - every 2 weeks, q4w - every 4 weeks, SD - standard deviation, and TARC is a thymus-regulated chemokine and activation.

†ACQ-5 is a patient-reported measure of adequate asthma control and change in asthma control that occurs either spontaneously or as a result of treatment. Higher scores indicate less control; the total score is calculated from 0 to 6.

‡AQLQ (S) is a patient-reported measure of the impact of asthma on quality of life. Higher scores indicate a better quality of life; the overall score is calculated from 1 to 7.

§Asthma symptom scores are patient-reported wake-up and evening assessments of asthma symptoms and their impact on activity (afternoon) and sleep (am). Higher scores indicate greater impairment; Symptoms are scored on a scale of 0 to 4.

Table 11. Subgroup analysis of primary endpoints by baseline blood eosinophils and FeNO levels.

Subgroup/Endpoint Randomized Treatment Group - ITT Population Placebo (N=317) 200 mg dupilumab q2w (N=631) Placebo (N=321) 300 mg dupilumab q2w (N=633) Baseline EOS ≥ 300 cells/µl Year-over-year frequency of severe exacerbations at week 52 N=148 N=264 N=142 N=277 Estimate (95% CI) 1.081 (0.846 to 1.382) 0.370 (0.289 to 0.475) 1.236 (0.972 to 1.571) 0.403 (from 0.317 to 0.512) Relative risk versus comparable placebo† - 0.342 (from 0.244 to 0.480) - 0.326 (from 0.234 to 0.454) P-value versus comparable placebo† <0.001 <0.001 Change from baseline FEV ₁ (l) at week 12 N=144 N=256 N=139 N=266 Change in mean value determined by LS (SE) 0.21 (0.03) 0.43 (0.03) 0.22 (0.03) 0.47 (0.02) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ - 0.21 (from 0.13 to 0.29) - 0.24 (from 0.16 to 0.32) P-value versus comparable placebo‡ <0.001 <0.001 Baseline EOS ≥ 150 cells/µl Year-over-year frequency of severe exacerbations at week 52 N=232 N=437 N=237 N=452 Estimate (95% CI) 1.007 (0.814 to 1.245) 0.445 (from 0.368 to 0.538) 1.081 (0.879 to 1.329) 0.434 (from 0.359 to 0.525) Relative risk versus comparable placebo† - 0.442 (from 0.337 to 0.581) - 0.402 (from 0.307 to 0.526) P-value versus comparable placebo† <0.001 <0.001 Change from baseline FEV ₁ (l) at week 12 N=224 N=425 N=229 N=434 Change in mean value determined by LS (SE) 0.18 (0.03) 0.36 (0.02) 0.22 (0.03) 0.37 (0.02) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ 0.17 (from 0.11 to 0.23) 0.15 (from 0.09 to 0.21) P-value versus comparable placebo‡ <0.001 <0.001 Baseline EOS < 300 cells/µl Year-over-year frequency of severe exacerbations at week 52 ^† N=169 N=366 N=178 N=356 Estimate (95% CI) 0.675 (from 0.515 to 0.884) 0.512 (0.418 to 0.628) 0.732 (from 0.562 to 0.954) 0.610 (from 0.502 to 0.742) Relative risk versus comparable placebo† - 0.759 (from 0.548 to 1.052) - 0.834 (from 0.608 to 1.144) P-value versus comparable placebo† 0.10 0.26 Change from Baseline FEV ₁ (L) at Week 12‡ N=163 N=354 N=173 N=344 Change in mean value determined by LS (SE) 0.15 (0.03) 0.23 (0.02) 0.18 (0.03) 0.22 (0.02) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ - 0.08 (from 0.01 to 0.15) - 0.04 (-0.03 to 0.11) P-value versus comparable placebo‡ 0.02 0.25 Baseline EOS < 150 cells/µl Year-over-year frequency of severe exacerbations at week 52 ^† N=85 N=193 N=83 N=181 Estimate (95% CI) 0.511 (from 0.346 to 0.755) 0.472 (from 0.358 to 0.623) 0.642 (0.445 to 0.927) 0.737 (0.575 to 0.946) Relative risk versus comparable placebo† - 0.925 (0.580 to 1.474) - 1.149 (0.747 to 1.767) P-value versus comparable placebo† 0.74 0.53 Change from Baseline FEV ₁ (L) at Week 12 ^‡ N=83 N=185 N=83 N=176 Change in mean value determined by LS (SE) 0.13 (0.04) 0.19 (0.03) 0.11 (0.04) 0.20 (0.03) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ - 0.06 (-0.04 to 0.15) - 0.09 (-0.01 to 0.18) P-value versus comparable placebo‡ 0.26 0.08 Initial FeNO ≥ 50 ppb Year-over-year frequency of severe exacerbations at week 52 N=71 N=119 N=75 N=124 Estimate (95% CI) 1.057 (0.722 to 1.547) 0.326 (from 0.221 to 0.480) 1.274 (0.901 to 1.801) 0.388 (from 0.270 to 0.558) Relative risk versus comparable placebo† - 0.308 (from 0.183 to 0.519) - 0.305 (from 0.188 to 0.494) P-value versus comparable placebo† <0.001 <0.001 Change from baseline FEV ₁ (l) at week 12 N=69 N=114 N=73 N=113 Change in mean value determined by LS (SE) 0.23 (0.05) 0.53 (0.04) 0.19 (0.05) 0.59 (0.04) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ - 0.30 (from 0.17 to 0.44) - 0.39 (from 0.26 to 0.52) P-value versus comparable placebo‡ <0.001 <0.001 Source FeNO ≥ 25 to 50 ppb Year-over-year frequency of severe exacerbations at week 52 N=91 N=180 N=97 N=186 Estimate (95% CI) 0.925 (from 0.648 to 1.322) 0.358 (from 0.258 to 0.495) 1.045 (0.739 to 1.478) 0.462 (from 0.343 to 0.622) Relative risk versus comparable placebo† - 0.386 (from 0.243 to 0.616) - 0.442 (from 0.282 to 0.693) P-value versus comparable placebo† <0.001 <0.001 Change from baseline FEV ₁ (l) at week 12 N=88 N=174 N=94 N=182 Change in mean value determined by LS (SE) 0.21 (0.04) 0.39 (0.03) 0.23 (0.04) 0.35 (0.03) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ - 0.19 (from 0.09 to 0.28) - 0.12 (from 0.03 to 0.21) P-value versus comparable placebo‡ <0.001 0.01 Initial FeNO <25 ppb Year-over-year frequency of severe exacerbations at week 52 N=149 N=325 N=144 N=317 Estimate (95% CI) 0.693 (0.525 to 0.916) 0.521 (from 0.418 to 0.650) 0.748 (from 0.565 to 0.992) 0.593 (from 0.478 to 0.735) Relative risk versus comparable placebo† - 0.752 (from 0.541 to 1.046) - 0.792 (from 0.572 to 1.098) P-value versus comparable placebo† 0.09 0.16 Change from baseline FEV ₁ (l) at week 12 N=144 N=316 N=141 N=309 Change in mean value determined by LS (SE) 0.15 (0.03) 0.20 (0.02) 0.20 (0.03) 0.23 (0.02) Difference in mean value determined by LS versus comparable placebo (95% CI)‡ - 0.05 (-0.02 to 0.12) - 0.03 (-0.04 to 0.10) P-value versus comparable placebo‡ 0.14 0.39

*CI is confidence interval, EOS is eosinophils, FeNO is exhaled nitric oxide fraction, FEV ₁ is forced expiratory volume in 1 second, LS is least squares, NA is not applicable, ppb is parts per billion, q2w is times per 2 weeks, q4w is every 4 weeks, and SE is the standard error.

†Derived using a negative binomial model with total events ranging from randomization to visit 18 or date of last contact as dependent variable; four treatment groups, age, region (country sum), baseline eosinophil level, baseline ICS dose level, and number of severe exacerbations in the year prior to study as covariates, and log-transformed standardized duration of follow-up as bias variable.

‡Change at week 12 from baseline was obtained using the MMRM approach with change from baseline in FEV ₁ values to bronchodilator administration at week 12 as dependent variable, and treatment, age, sex, baseline height, region (country total), baseline eosinophils, baseline ICS dose, visit, interaction with treatment factor effect versus visit, baseline FEV ₁ before bronchodilator administration, and interaction with baseline factor effect versus visit as covariates.

Table 12. Summary of additional secondary endpoints.

end point Randomized treatment group placebo
(N=317) 200 mg dupilumab q2w
(N=631) placebo
(N=321) 300 mg dupilumab q2w (N=633) Change from Baseline in Total AQLQ(S) at Week 24 Change in mean value determined by LS (SE) 0.94 (0.06) 1.14 (0.04) 1.00 (0.06) 1.15 (0.04) Difference in mean value determined by LS versus comparable placebo (95% CI) † - 0.20 (from 0.06 to 0.34) - 0.15 (from 0.01 to 0.28) P-value versus comparable placebo† 0.004 0.03 Change from Baseline in Total AQLQ(S) at Week 52 Change in mean value determined by LS (SE) 0.99 (0.06) 1.28 (0.04) 1.03 (0.06) 1.29 (0.04) Difference in mean value determined by LS versus comparable placebo (95% CI) † - 0.29 (0.15, 0.44) - 0.26 (0.12, 0.40) P-value versus comparable placebo† <0.001 <0.001 Change from baseline in total AQLQ (S) at week 24 in patients with ≥ 300 eosinophils/μL Change in mean value determined by LS (SE) 0.96 (0.09) 1.37 (0.06) 0.98 (0.09) 1.32 (0.06) Difference in mean value determined by LS versus comparable placebo (95% CI) † - 0.41 (from 0.20 to 0.62) - 0.34 (from 0.13 to 0.54) P-value versus comparable placebo† <0.001 0.001 Change from baseline in ACQ-5 score at week 2 Change in mean value determined by LS (SE) −0.56 (0.05) −0.89 (0.04) −0.61 (0.05) −0.92 (0.04) Difference in mean value determined by LS compared to comparable placebo (95% CI) ‡ - -0.34 (-0.46, -0.22) - -0.31 (-0.42, -0.19) P-value versus comparable placebo‡ <0.001 <0.001 Change from baseline in ACQ-5 score at week 24 Change in mean value determined by LS (SE) −1.10 (0.06) −1.44 (0.04) −1.21 (0.06) −1.40 (0.04) Difference in mean value determined by LS compared to comparable placebo (95% CI) ‡ - -0.35 (from -0.48 to -0.21) - -0.19 (from -0.32 to -0.05) P-value versus comparable placebo‡ <0.001 0.007 Change from baseline in ACQ-5 at week 52 Change in mean value determined by LS (SE) −1.15 (0.06) −1.54 (0.04) −1.30 (0.06) −1.52 (0.04) Difference in mean value determined by LS compared to comparable placebo (95% CI) ‡ - -0.39 (-0.53, -0.25) - -0.22 (-0.36, -0.08) P-value versus comparable placebo‡ <0.001 0.002 Change from baseline symptom score before noon in week 24 Change in mean value determined by LS (SE) −0.33 (0.03) −0.52 (0.02) −0.37 (0.03) −0.49 (0.02) Difference in mean value determined by LS compared to comparable placebo (95% CI) § -0.19 (from -0.27 to -0.11) -0.12 (from -0.20 to -0.04) P-value versus comparable placebo§ <0.001 0.004 Change from baseline symptom score before noon at week 52 Change in mean value determined by LS (SE) −0.40 (0.04) −0.55 (0.03) −0.43 (0.04) −0.58 (0.03) Difference in mean value determined by LS compared to comparable placebo (95% CI) § -0.15 (from -0.24 to -0.06) -0.16 (from -0.24 to -0.07) P-value versus comparable placebo§ <0.001 <0.001 Change from baseline in symptom score in the afternoon of week 24 Change in mean value determined by LS (SE) −0.33 (0.04) −0.53 (0.03) −0.36 (0.04) −0.51 (0.03) Difference in mean value determined by LS compared to comparable placebo (95% CI)§ -0.20 (from -0.28 to -0.11) -0.15 (from -0.24 to -0.06) P-value versus comparable placebo§ <0.001 <0.001 Change from baseline in symptom score in the afternoon of week 52 Change in mean value determined by LS (SE) −0.39 (0.04) −0.57 (0.03) −0.42 (0.04) −0.57 (0.03) Difference in mean value determined by LS compared to comparable placebo (95% CI)§ -0.18 (from -0.28 to -0.09) -0.14 (from -0.24 to -0.05) P-value versus comparable placebo§ <0.001 0.003 Change from baseline PEF (L/min) to noon in week 24 Change in mean value determined by LS (SE) 6.15 (3.49) 28.19 (2.51) 15.61 (3.47) 25.01 (2.50) Difference in mean value determined by LS compared to comparable placebo (95% CI) ¶ 22.04 (from 13.70 to 30.38) 9.40 (from 1.11 to 17.68) P-value versus comparable placebo¶ <0.001 0.03 Change from baseline PEF (L/min) to noon at week 52 Change in mean value determined by LS (SE) 2.35 (3.94) 28.97 (2.82) 12.69 (3.91) 26.00 (2.82) Difference in mean value determined by LS versus comparable placebo (95% CI)¶ 26.62 (from 17.20 to 36.04) 13.31 (from 3.94 to 22.67) P-value versus comparable placebo¶ <0.001 0.005 Change from Baseline PEF (L/min) PM Week 24 Change in mean value determined by LS (SE) −2.86 (3.52) 19.62 (2.53) 8.14 (3.51) 16.53 (2.52) Difference in mean value determined by LS versus comparable placebo (95% CI)¶ 22.48 (from 14.08 to 30.89) 8.39 (from 0.03 to 16.74) P-value versus comparable placebo¶ <0.001 0.049 Change from Baseline PEF (L/min) PM Week 52 Change in mean value determined by LS (SE) −6.01 (3.96) 17.50 (2.84) 4.44 (3.95) 15.34 (2.84) Difference in mean value determined by LS versus comparable placebo (95% CI)¶ 23.51 (from 14.04 to 32.99) 10.90 (from 1.47 to 20.32) P-value versus comparable placebo¶ <0.001 0.024 1.14 ml and 2 ml placebo q2w combined (N=638) 200 mg and 300 mg dupilumab q2w combined (N=1264) Year-over-year frequency of severe exacerbation events requiring hospitalization or ER visit Estimate (95% CI) 0.065 (from 0.047 to 0.090) 0.035 (from 0.025 to 0.048) Relative risk versus comparable placebo# 0.532 (from 0.347 to 0.816) P-value versus comparable placebo# 0.004

* ACQ-5 denotes the 5-item version of the Asthma Control Questionnaire, AQLQ is the Asthma Quality of Life Questionnaire, CI is the confidence interval, ER is the Emergency Department, LS is the least squares method, PEF is the maximum expiratory flow rate, q2w is every 2 weeks, q4w every 4 weeks, and SE the standard error.

†Derived from MMRM model with change from baseline in total AQLQ to week 24 or 52 as dependent variable and four treatment groups, age, region (country total), baseline eosinophils, baseline ICS dose level, visit, interaction with effect treatment factor vs. visit, baseline total AQLQ, and interaction with baseline factor vs. visit as covariates.

‡Derived from MMRM model with change from baseline ACQ-5 to week 24 or 52 as dependent variable and four treatment groups, age, region (country total), baseline eosinophil level, baseline ICS dose level, visit, interaction with effect treatment factor vs. visit, baseline ACQ-5, and interaction with baseline factor vs. visit as covariates.

§Derived from an MMRM model with change from baseline in symptom score AM/PM (periodic mean) to week 52 as dependent variable and treatment, age, area (country total), baseline eosinophil level, baseline ICS dose level, by visit, interaction with treatment factor effect by visit, baseline symptom score am/pm, and interaction with baseline factor effect by visit as covariates.

¶Derived from an MMRM model with change from baseline in AM/PM PEF values (periodic mean) to week 52 as dependent variable and treatment, age, sex, baseline height, area (country total), baseline eosinophils, baseline ICS dose level, visit, interaction with treatment factor effect versus visit, baseline AM/PM PEF, and interaction with baseline factor effect versus visit as covariates.

#Derived using a negative binomial model with total events ranging from randomization to visit 18 or date of last contact as dependent variable; two treatment groups pooled, age, area (country sum), baseline eosinophil level, baseline ICS dose level, and number of severe exacerbations in the year prior to study as covariates, and log-transformed standardized length of follow-up as bias variable.

Table 13. Summary of change from baseline biomarker type 2 levels.

Randomized treatment group Placebo (N=317) 200 mg dupilumab q2w (N=631) Placebo (N=321) 300 mg dupilumab q2w (N=633) Nitric oxide fraction in exhaled air Mean value at baseline (SD) - ppb 34.5 (28.7) 34.4 (34.9) 38.4 (38.0) 34.0 (29.8) Median value (min - max) at baseline - ppb 26.0 (from 3 to 197) 23.0 (from 3 to 387) 27.0 (from 5 to 351) 24.0 (from 4 to 202) Change from baseline to week 12 Change in Mean (SD) - ppb −2.4 (21.1) −15.1 (31.4) −3.6 (29.6) −15.8 (25.2) Change in mean value (SD) - % 8.641 (68.047) −21.954 (49.522) 5.794 (63.044) −27.254 (46.861) Change in median value (min - max) - ppb -1.0 (-81 to 78) -6.0 (-371 to 69) -1.0 (-309 to 69) -7.0 (-177 to 62) Change in median value (min - max) - % −6.782
(from -83.93 to 500.00) −29.289
(from -95.87 to 360.00) −5.814
(from -91.96 to 450.00) −34.615
(from -93.16 to 266.67) Change from baseline to week 24 Change in Mean (SD) - ppb −2.9 (21.3) −16.6 (32.8) −4.6 (30.2) −16.6 (25.9) Change in mean value (SD) - % 9.774 (70.868) −24.710 (49.373) 4.383 (72.603) −28.165 (50.465) Change in median value (min - max) - ppb -1.0 (-96 to 122) -7.0 (-373 to 42) -2.0 (-306 to 96) -8.0 (from -171 to 29) Change in median value (min - max) - % −6.667
(from -87.50 to 583.33) −33.333
(from -97.16 to 420.00) −10.526
(from -91.07 to 620.00) −38.462
(from -92.26 to 580.00) Change from baseline to week 52 Change in Mean (SD) - ppb −2.1 (20.7) −16.5 (27.3) −5.2 (36.0) −16.5 (27.0) Change in mean value (SD) - % 5.494 (58.379) −28.705 (47.319) 1.561 (61.831) −26.450 (57.383) Change in median value (min - max) - ppb -1.0 (-76 to 103) -8.0 (from -188 to 46) -2.0 (-307 to 218) -8.0 (from -177 to 54) Change in median value (min - max) - % −5.882
(from -82.35 to 381.48) −37.931
(from -96.41 to 383.33) −10,000
(from -91.37 to 380.00) −37,500
(from −93.44 to 600.00) Total IgE (IU/ml) Baseline Mean (SD) - IU/mL 394.2 (626.2) 460.6 (816.6) 448.5 (796.7) 415.0 (701.4) Median value (min - max) at baseline - IU / ml 174.5 (from 1 to 5000) 154.0 (from 1 to 5000) 178.5 (from 3 to 5000) 174.0 (from 1 to 5000) Change from baseline to week 12 Change in mean value (SD) - IU/ml 11.6 (306.6) −161.9 (327.3) −4.5 (174.1) −143.9 (304.3) Change in mean value (SD) in IU/ml - % 24.088 (349.934) −18.998 (207.581) 3.062 (33.718) −10.317 (488.825) Change in the median value (min - max) - IU / ml −1.0 (−1044 to 4545) -53.0 (from -2612 to 687) -1.0 (from -791 to 1337) −57.0 (−4974 to 1384) Change in median value (min - max) - % −1.875
(from −55.18 to 6060.00) −35.356
(from -94.85 to 3816.67) −0.327
(from -53.95 to 266.67) −36.364
(from -99.48 to 11600.00) Change from baseline to week 24 Change in mean value (SD) - IU/ml 13.9 (304.3) −246.6 (462.5) 33.9 (372.8) −217.0 (369.1) Change in mean value (SD) in IU/ml - % 28.049 (306.538) −44.719 (98.770) 28.770 (380.881) −47.871 (65.897) Change in the median value (min - max) - IU / ml -1.0 (from -1654 to 3851) -85.0 (-4007 to 571) -1.0 (-931 to 3478) -88.0 (-4241 to 871) Change in median value (min - max) - % −2.020
(from -70.83 to 5134.67) −53.280
(from −98.97 to 1841.94) −0.697
(from -65.31 to 6485.71) −53.913
(from -99.18 to 1060.00) Change from baseline to week 52 Change in mean value (SD) - IU/ml 2.2 (433.3) −318.1 (582.3) −3.9 (323.2) −303.4 (521.7) Change in mean value (SD) in IU/ml - % 32.774 (436.822) −61.817 (67.319) 8.203 (64.731) −59.547 (160.018) Change in the median value (min - max) - IU / ml -3.0 (from -1704 to 4925) -110.0 (from -4637 to 573) -3.0 (-1000 to 3246) -119.0 (from -4994 to 509) Change in median value (min - max) - % -3.271 (from -68.51 to 6566.67) -69.427 (from -96.91 to 1202.70) -4.444 (from -80.12 to 652.94) -70.258 (from -99.88 to 3360.00) The content of eosinophils in the blood (cells/µl) Baseline Mean (SD) - cells/µl 370 (338) 349 (345) 391 (419) 351 (369) Median value (min - max) at baseline - cells/µl 270 (0-2200) 250 (0-3610) 265 (0-3580) 250 (0-4330) Change from baseline to week 12 Change in mean value (SD) - cells/µl −12.66 (269.52) 118.31 (539.03) −43.3 (350.43) 88.88 (532.6) Change in mean value (SD) - % 46.375 (172.116) 78.610 (403.288) 34.649 (181.064) 93.299 (576.646) Change in median value (min - max) - cells/µl 5 (-1610 to 1630) 10 (-1790 to 5350) -10 (from -2220 to 1180) 0 (-2970 to 6660) Change in median value (min - max) - % 0.000 (-100.00 to 1400.00) 2.986 (-97.67 to 6900.00) −3.704 (from −100.00 to 1700.00) 0.000 (-100.00 to 10100.00) Change from baseline to week 24 Change in mean value (SD) - cells/µl −23.556 (335.679) 86.52 (622.63) −32.049 (376.45) 49.657 (494.575) Change in mean value (SD) - % 39.519 (156.576) 62.538 (250.177) 49.673 (252.040) 68.958 (367.619) Change in median value (min - max) - cells/µl 0 (-1290 to 2630) 0 (-2170 to 10200) 0.000 (-2970 to 1390) 0 (-3080 to 5350) Change in median value (min - max) - % 0.000 (-100.00 to 1200.00) 0.000 (-100.00 to 2850.00) 0.000 (-100.00 to 2300.00) 0.000 (-100.00 to 5800.00) Change from baseline to week 52 Change in mean value (SD) - cells/µl −2.78 (313.82) 23.849 (399.395) −47.88 (344.83) −2.26 (425.596) Change in mean value (SD) - % 115.548 (876.073) 28.472 (150.256) 33.603 (206.264) 43.764 (301.609) Change in median value (min - max) - cells/µl 0 (-1670 to 1540) -20 (from -1690 to 3170) -30 (from -2330 to 1740) -25 (from -3670 to 3420) Change in median value (min - max) - % 0.000 (-99.26 to 12800.00) -9.091 (from -100.00 to 1900.00) −11.438 (from −100.00 to 2400.00) −14.583 (from −100.00 to 4300.00) Thymus-activated chemokine (TARC; pg/mL) Baseline Mean (SD) - pg/mL 377.8 (289.0) 393.8 (457.4) 398.0 (344.2) 364.7 (295.4) Median value at baseline (min - max) - pg / ml 296 (from 33 to 1970) 314.5 (from 16 to 8600) 300 (from 34 to 3210) 295 (from 16 to 3170) Change from baseline to week 12 Change in mean value (SD) - pg/ml −12.6 (199.2) −153.6 (392.3) 29.9 (472.7) −139.9 (226.8) Change in mean value (SD) - % 9.537 (57.893) −26.434 (40.121) 14.583 (77.359) −24.414 (86.001) Change in the median value (min - max) - pg / ml −1 (from −1554 to 800) -96.5 (from -7560 to 835) -7.1 (-617 to 7850) -96.4 (from -2011 to 1674) Change in median value (min - max) - % -0.645 (from -95.36 to 427.81) -32.883 (from -90.71 to 236.97) -3.815 (from -77.37 to 827.81) -34.559 (from -91.79 to 1747.6) Change from baseline to week 24 Change in mean value (SD) - pg/ml 0.6 (279.0) −160.5 (427.0) 118.0 (2206.6) −135.8 (215.8) Change in mean value (SD) - % 12.279 (75.287) −26.666 (46.770) 16.714 (115.621) −26.925 (38.823) Change in the median value (min - max) - pg / ml -10.0 (from -1525 to 2820) -103.5 (from -7629 to 2327) -0.0 (-910 to 37250) −93.0 (−2005 to 590) Change in median value (min - max) - % -3.175 (from -83.53 to 580.58) -34.988 (from -94.24 to 313.19) 0.000 (-79.92 to 1354.55) -34.251 (from -92.12 to 211.47) Change from baseline to week 52 Change in mean value (SD) - pg/ml −11.4 (197.9) −161.4 (450.9) 138.3 (2169.6) −125.2 (219.5) Change in mean value (SD) - % 11.384 (69.774) −27.018 (42.836) 26.028 (148.647) −23.379 (50.305) Change in the median value (min - max) - pg / ml −5.0 (−1456 to 1090) -101.0 (from -8187 to 885) 8.0 (-669 to 33650) -90.0 (from -2196 to 590) Change in median value (min - max) - % -2.419 (from -86.99 to 519.34) -33.544 (from -97.86 to 233.64) -2.226 (from -70.99 to 1725.64) -34.483 (from -91.24 to 586.71) Periostin (ng/ml) Baseline Mean (SD) - ng/mL 79.83 (36.60) 79.85 (39.12) 80.94 (40.73) 78.42 (37.94) Median value at baseline (min - max) - ng / ml 72.1 (from 27.8 to 244.9) 70.6 (from 20.5 to 368.2) 71 (from 25.1 to 312.8) 69.7 (from 19.2 to 298.5) Change from baseline to week 12 Change in mean value (SD) - ng/ml −1.22 (23.46) −16.52 (32.20) −1.27 (26.71) −15.54 (29.51) Change in mean value (SD) - % 2.118 (27.112) −12.795 (29.683) 1.911 (28.007) −13.554 (26.622) Change in the median value (min - max) - ng / ml -0.6 (from -119.7 to 106.6) -8.40 (from -266.4 to 66.4) -0.6 (from -103.5 to 127.6) -10.65 (from -234.5 to 77.8) Change in median value (min - max) - % -1.211 (from -48.88 to 121.94) -13.483 (from -75.76 to 296.59) -1.068 (from -92.47 to 141.78) −15.350 (from −78.56 to 105.03) Change from baseline to week 52 Change in mean value (SD) - ng/ml −4.79 (22.23) −18.83 (34.79) −5.24 (27.29) −19.49 (30.37) Change in mean value (SD) - % −2.004 (25.992) −15.065 (31.303) −2.538 (29.531) −18.187 (24.427) Change in the median value (min - max) - ng / ml -3.90 (from -108.4 to 75.7) −11.40 (from −260 to 70.4) -4.20 (from -110.3 to 189.5) -12.65 (from -202.4 to 38.2) Change in median value (min - max) - % -5.410 (from -70.89 to 134.18) -17.213 (from -77.16 to 343.41) -6.988 (from -70.84 to 236.28) -19.719 (from -72.28 to 75.11) Eotaxin-3 (pg/ml) Baseline Mean (SD) - pg/mL 52.172 (86.619) 78.202 (339.495) 50.892 (57.855) 69.516 (481.528) Median value at baseline (min - max) - pg / ml 36.5 (from 1.95 to 1180) 39.2 (from 1.95 to 6430) 37.45 (from 1.95 to 723) 38.3 (from 1.95 to 12000) Change from baseline to week 12 Change in mean value (SD) - pg/ml −3.157 (27.405) −35.661 (137.286) −1.795 (30.136) −39.233 (355.197) Change in mean value (SD) - % 20.179 (145.501) −14.212 (137.332) 30.046 (260.896) −25.550 (107.262) Change in the median value (min - max) - pg / ml -0.2 (from -164 to 114.8) −14.650 (from −2110 to 245.3) 0 (-233 to 119.6) −14,000 (from −8750 to 33) Change in median value (min - max) - % -0.719 (from -95.19 to 1571.73) -39.587 (from -98.78 to 1443.59) 0 (-96.89 to 3858.97) -40.977 (from -98.73 to 1264.1) Change from baseline to week 24 Change in mean value (SD) - pg/ml −1.483 (34.127) −31.796 (153.247) −6.335 (35.606) −44.278 (448.676) Change in mean value (SD) - % 33.047 (191.426) −17.149 (136.065) 15.413 (139.984) −24.072 (108.415) Change in the median value (min - max) - pg / ml -0.700 (from -235.00 to 270.00) −16.900 (from −2872.00 to 1650.00) −2.500 (from −315.20 to 200.60) −13.600 (from −10690.00 to 113.40) Change in median value (min - max) - % -3.101 (from -96.88 to 1889.74) -42.700 (from -98.78 to 1458.97) -7.734 (from -96.88 to 1315.38) -40.326 (from -98.61 to 1587.18) Change from baseline to week 52 Change in mean value (SD) - pg/ml −1.341 (52.531) 62.496 (2227.767) −1.178 (42.275) −50.095 (533.671) Change in mean value (SD) - % 27.331 (132.523) −3.527 (210.111) 52.327 (304.987) −23.606 (113.851) Change in the median value (min - max) - pg / ml 0.000 (-528.00 to 337.30) −12.900 (from −3178.00 to 48070.00) −0.850 (from −312.10 to 205.90) −14.100 (from −11374.00 to 222.50) Change in median value (min - max) - % 0.000 (-94.07 to 1094.87) -35.157 (from -99.58 to 3294.87) -2.729 (from -95.14 to 3156.41) -39.962 (from -97.19 to 1780.00)

*min - max stands for minimum to maximum, ppb - parts per billion, q2w - biweekly, and SD - standard deviation.

Table 14 Summary of Interaction Test for Effectiveness.

P-value for dupilumab 200 mg q2w versus matched placebo P-value for dupilumab 300 mg q2w versus matched placebo Overall P-value Annualized rate of severe exacerbation during the 52-week treatment period* The content of eosinophils in the blood (cells/µl) <0.001 <0.001 <0.001 FeNO(ppb) 0.0076 <0.001 <0.001 Periostin (ng/ml) 0.1667 0.1347 0.1046 ECP (ng/ml) 0.0766 0.1302 0.079 Total IgE (IU/ml) 0.4161 0.2755 0.3036 TARC (pg/ml) 0.9688 0.5591 0.7689 Eotaxin-3 (pg/ml) 0.8099 0.1845 0.4494 FEV ₁ before bronchodilator administration at week 12† The content of eosinophils in the blood (cells/µl) 0.0361 <0.001 <0.001 FeNO(ppb) <0.001 <0.001 <0.001 Periostin (ng/ml) 0.0154 0.0195 <0.001 ECP (ng/ml) 0.3076 0.0049 0.0102 Total IgE (IU/ml) 0.0270 0.0483 0.0245 TARC (pg/ml) 0.6540 0.3062 0.3759 Eotaxin-3 (pg/ml) 0.0421 0.0134 0.0151

* P-values for testing treatment factor interaction effects by biomarker based on non-penalty negative binomial regression spline models in the ITT population.

† P-values for testing biomarker-dependent treatment factor interaction effects based on penalized spline regression models in the ITT population.

Discussion

Dupilumab provided a significant reduction in the annual summary of severe exacerbations in the ITT population, with stronger treatment effects observed with increases in baseline blood eosinophils and FeNO. Dupilumab also provided a significant reduction in the most severe asthma exacerbations requiring hospitalization or an emergency department visit. Evaluation of FEV ₁ and asthma control over time indicated that dupilumab's efficacy was rapid, with significant differences compared to placebo presenting as early as the first evaluation at week 2 and persisting through the 52-week treatment period for both dosing regimens. Significant and clinically significant improvements in FEV ₁ from 0.32 to 0.34 L were observed at week 12 regardless of baseline blood eosinophil counts, with an even larger increase from 0.43 to 0.47 L in patients with baseline blood eosinophil counts ≥ 300 eosinophils/µl.

In addition, slope analysis for FEV ₁ after bronchodilator administration showed that compared to the loss of lung function observed in patients treated with placebo, no loss was observed in patients treated with dupilumab, indicating a potential effect of dupilumab in regarding airway remodeling. Slope analysis showed that placebo patients lost an average of approximately 40 mL per year, consistent with data from other asthma cohorts. In addition, since IL-4Rα is expressed on smooth muscle cells, it is possible that there is a direct bronchodilator effect of the drug in addition to effects on type 2 inflammatory factors.

The consistent and profound improvement seen with dupilumab is likely due to its unique mechanism of action. With the recent focus of the asthma community on exacerbations driven by concerns about cost-effectiveness, the focus has shifted away from the serious morbidity and quality of life issues associated with the significant loss of lung function seen in patients with asthma from moderate to severe. Despite modern therapies, these patients with moderate to severe asthma are destined to continue to lose lung function and experience disease progression over time. Thus, the possibility that a new treatment can provide a significant recovery of clinically relevant levels of lung function, and perhaps even prevent further deterioration, could be of enormous benefit to these patients.

The results of this study confirm that interleukin-4 and interleukin-13 are key proximal factors in type 2 inflammation in asthma. Dupilumab is the first biologic to significantly reduce FeNO levels, in addition to other type 2 systemic biomarkers such as IgE, confirming its biological activity in airway inflammation. Without wishing to be bound by scientific theory, dupilumab's unique mechanism of action with dual blockade of interleukin-4 and interleukin-13 signaling may explain why dupilumab demonstrates a significant treatment effect in a wider patient population and an unprecedented effect in improving lung function, suggesting a potential direct bronchodilator effect in addition to its anti-inflammatory effect. Of note, this study shows the most significant association of benefit with baseline blood eosinophil levels compared to the other two pivotal studies with dupilumab. Although there is no clear explanation why this association was more prominent in this study, blood eosinophil counts may not be an adequate measure of type 2 inflammation, indicating that other biomarkers of type 2 inflammation, such as FeNO, may be important. However, overall in all three studies, dupilumab appears to target a broader asthma population than populations defined only by elevated blood levels of eosinophils or IgE, as required for other approved biologics.

Dupilumab has been shown to be active against several atopic/allergic conditions that are often associated with asthma patients. In this study, more than 80% of patients suffered from comorbid atopic or allergic conditions, including atopic dermatitis (approximately 10% of the population), nasal polyposis (approximately 20% of the population) and allergic rhinitis (more than 65% of the population). The high rate of comorbid atopic/allergic conditions suggests that these patients suffer from systemic overactivity of the type 2 inflammatory axis and thus asthma treatment with dupilumab may simultaneously help alleviate these associated conditions.

Dupilumab was generally well tolerated and had an acceptable safety profile. With the exception of injection site reactions, the incidence of TEAE was similar in the treatment groups. Consistent with the mechanism of action and similar to that observed in the atopic dermatitis trials, patients treated with dupilumab experienced a greater mean transient increase from baseline in blood eosinophils compared to placebo. According to the study protocol, all cases of eosinophils > 3000 cells/µl during treatment were to be recorded as AE in this study. Most observed cases of elevated eosinophils were laboratory findings with no clinical sequelae or associated AEs. The increase in blood eosinophils is consistent with the hypothesis that dupilumab blocks the function of interleukin-4 and interleukin-13 in terms of survival, activation and recruitment of eosinophils in tissue, but not return from the bone marrow, which is affected by IL-5. As a result, primary treatment with dupilumab may lead to a transient increase in circulating eosinophils in the blood. No treatment-related AE conjunctivitis was observed between the dupilumab and placebo groups, in contrast to studies of dupilumab in atopic dermatitis.

In conclusion, the largest study to date of dupilumab in patients with uncontrolled moderate to severe asthma demonstrates here that dual blockade of interleukin-4 and interleukin-13 with dupilumab is an effective treatment for a broad population with asthma, providing a significant reduction in the incidence of severe exacerbations, rapid and sustained improvements in lung function and asthma control, as well as symptom relief. The most significant results were observed in patients with elevated type 2 immune characteristics, including the content of eosinophils and FeNO. Dupilumab is the only biologic shown to be effective in multiple studies in patients with moderate to severe asthma, regardless of baseline levels of type 2 biomarkers. Dupilumab was generally well tolerated and had an acceptable safety profile. These data support the use of dupilumab as an effective add-on therapy for this population of asthma patients with high unmet need.

Example 3 Phase III trial of the QUEST study. Dupilumab reduces the rate of severe exacerbations and improves lung function in adolescent patients with moderate to severe uncontrolled asthma

The prevalence of asthma in children and adolescents has increased over the past 30 years (Asher (2014) Int. J. Tuberc. Lung Dis.). In 2011, approximately 11.4% of adolescents (ages 12-17) in the US reported that they currently have asthma (Bloom (2011) Vital and Health Statistics Series).

The incidence of asthma in adolescents is the same (or often higher) as in younger children, but adolescents are less likely to seek medical help (Couriel (2003) J. Pediatric Resp. Rev.). Many adolescents underestimate the severity of their asthma and overestimate their susceptibility to bronchodilators (Rhee (2008) J. Asthma; Andersson (2013) Pediatrics). Asthma has a profound impact on the physical, psychological and social health of adolescents and negatively affects health-related quality of life (Cui (2016) J. Pediatrics).

This study evaluated the efficacy and safety of dupilumab in a subgroup of adolescents (aged 12–17 years) and adults (aged ≥ 18 years) with moderate to severe uncontrolled asthma. The endpoints assessed over the 52-week treatment period were the annual rate of severe exacerbations and the change from baseline FEV ₁ to bronchodilator administration (l). Baseline demographics and clinical characteristics are shown in FIG. 12.

Inclusion Criteria. Age ≥ 12 years with physician-diagnosed uncontrolled asthma for ≥ 12 months (Global Initiative on Asthma (GINA) 2014); being treated with medium to high dose ICS (inhaled corticosteroids) plus no more than 2 additional controller medications; FEV ₁ (forced expiratory volume in 1 second) before bronchodilator administration ≤ 80% predicted (adults) and ≤ 90% (adolescents) at screening and baseline; reversibility after bronchodilator ≥ 12% and 200 ml; ACQ-5 score (5-item asthma control questionnaire) ≥ 1.5 at screening and at baseline; ≥ 1 exacerbation in the previous year; the absence of minimum requirements for the initial content of eosinophils in the blood or any other type 2 biomarker.

exclusion criteria. chronic obstructive pulmonary disease or other lung conditions that can impair lung function; severe asthma exacerbation within 1 month of the inclusion visit or during the screening period; active smoker, smoker who quit smoking within 6 months prior to screening or with a history of smoking >10 pack-years; concomitant disease that may interfere with the evaluation of the investigational medicinal product.

Statistical analysis. Efficacy analysis was performed on the ITT population, defined as all randomized patients analyzed according to the prescribed treatment, regardless of the treatment received.

The annualized frequency of severe asthma exacerbations during the 52-week treatment period was analyzed using a negative binomial regression model. Changes from baseline FEV ₁ at different time points during the 52-week treatment period were analyzed using a repeated measures mixed effects model.

The primary endpoints, the incidence of severe asthma exacerbation and FEV ₁ , were also analyzed in patient subgroups defined by age (< 18 years and > 18 years). The safety population included all patients who received ≥ 1 dose or fraction of a dose of investigational treatment, analyzed according to treatment received.

Dupilumab reduced severe exacerbations and improved FEV ₁ in the general ITT population (Fig. 13A and Fig. 13B), reduced the rate of severe exacerbation in adolescents and adults (Fig. 14A and Fig. 14B), and improved FEV ₁ at week 12 (Fig. 15A) and week 52 (FIG. 15B), as well as during the 52 week treatment period (FIGS. 16A and 16B) in adolescents and adults.

Dupilumab provided an improvement in the predicted percentage of FEV ₁ over a 52-week treatment period in adolescents and adults (FIG. 18A and FIG. 18B). FeNO levels (Figure 19A and Figure 19B), ACQ-5 scores (Figure 20A and Figure 20B), and AQLQ scores (Figure 21A and Figure 21B) were assessed.

Adolescents comprised 107/1902 patients included (34 in dupilumab groups, 21/18 in matched placebo groups); 35.5% were women, mean baseline FEV1 2.33 L, mean predicted FEV1 % 70.45%, mean number of severe exacerbations in the previous year 1.91. Placebo-treated adolescents experienced fewer severe exacerbations (0.36/0.33) than adults (0.89/1.00). In adolescents, dupilumab 200 mg provided a 46.4% year-on-year reduction in exacerbations, while dupilumab 300 mg had no treatment effect compared to placebo (not wanting to be bound by a scientific theory, this could be due to a small sample size and unbalanced number of antecedent events (mean 1.53 versus 2.22, respectively)). The unadjusted exacerbation rate was 0.46 (300 mg dupilumab) and 0.76 (placebo). Significant improvements in change from baseline in FEV1 (l) compared with placebo were observed in adolescents (200 mg dupilumab: least squares mean 0.36 [95% CI 0.12-0.61]; 300 mg: 0 .27 [0.02-0.52]) (P < 0.05), and they were numerically higher compared to adults (200 and 300 mg: 0.12 [0.07-0.18]).

The adverse event profile was comparable between subgroups (Fig. 17, Fig. 22, Fig. 23 and Fig. 24). The most common treatment-emergent adverse events (TEAEs) most common in the pooled dupilumab arm were: in adolescents, viral respiratory tract infections (placebo 2 [5.1%]); dupilumab 7 [10.3%]); in adults, erythema at the injection site (placebo 34 [5.7%]; dupilumab 168 [14.1%]). Eosinophilia has been observed only in the adult population.

Dupilumab provided a significant year-over-year reduction in severe exacerbations and improvement in lung function in adults with moderate to severe uncontrolled asthma. Improvement in FEV ₁ was rapid and sustained over the 52 week treatment period. Dupilumab also provided a significant improvement in lung function in adolescents with uncontrolled moderate to severe asthma, with a numerical reduction in severe exacerbations.

As in adults, in adolescents, improvement in FEV ₁ was rapid and sustained over the 52-week treatment period. The magnitude of improvement in FEV ₁ was higher in adolescents. Dupilumab was generally well tolerated.

Example 4 Phase III trial of the QUEST study. Dupilumab improves health-related quality of life in rhinoconjunctivitis, improves lung function, and reduces severe exacerbations in patients with moderate to severe asthma

Health-related quality of life in patients with comorbid allergic rhinitis

Allergic rhinitis (AR), a common type 2 comorbidity in patients with asthma, contributes to the overall disease burden. This analysis of the Phase 3 LIBERTY ASTHMA QUEST (NCT02414854) study in patients with uncontrolled moderate to severe asthma assessed the effect of dupilumab on the Rhinoconjunctivitis Standardized Quality of Life Questionnaire score [RQLQ(S)+12] in patients with self-reported comorbid AR .

Asthma patients ≥ 12 years of age uncontrolled with moderate to high ICS plus ≤ 2 additional control agents received an additional 200/300 mg dupilumab or comparable placebo every 2 weeks (q2w) for 52 weeks. Patients with a history of self-reported AR (63.5%; n/N=1207/1902) completed the validated RQLQ(S) + 12 at weeks 12 and 52. No clinical diagnosis of AR was recorded.

Total RQLQ (S) + 12 (baseline mean [SD] 1.90 [1.12] - 2.01 [1.16]) significantly improved with dupilumab 200/300 mg q2w compared with placebo at week 52 (difference for least squares mean [95% CI] −0.42 [−0.61, −0.24]/−0.39 [−0.56, −0.21]; P < 0.0001). 200/300 mg dupilumab provided significant (P < 0.001) improvements in performance domains (0.44 [0.68, 0.21]/0.39 [0.61, 0.16]), sleep (0.47 [0.69, 0.25] / 0.38 [0.59, 0.17]) and eye symptoms (0.37 [0.58, 0.16] / 0.39 [0.59, 0, 19]) from baseline to week 52 compared to placebo; and by week 12 for dupilumab 300 mg (0.23 [0.42, 0.04], 0.26 [0.45, 0.07], 0.26 [0.45, 0.08], respectively; P < 0.05). Nasal symptom domain scores improved significantly with dupilumab 200/300 mg versus placebo at week 12 (0.36 [0.56, 0.16]/0.32 [0.51, 0.13]; P< 0.001) and by week 52 (0.61 [0.84, 0.39]/0.55 [0.76, 0.33]; P < 0.0001). The most common adverse event with a higher frequency with dupilumab compared with placebo was an injection site reaction (15%/18% versus 5%/10%).

Dupilumab provided a significant improvement in rhinoconjunctivitis-specific health-related quality of life in patients with uncontrolled moderate to severe asthma and comorbid AR and was generally well tolerated.

Population: Patients with comorbid AR. Endpoints/Visit: Change in LS-defined mean from baseline over a 52-week treatment period for RQLQ domains (nasal symptoms, ocular symptoms, activity, sleep); security (ITT). Treatment groups: 200 mg and 300 mg dupilumab q2w and matched placebo.

Improvement in lung function and reduction in severe exacerbation in patients with or without concomitant allergic rhinitis

In a retrospective analysis of the phase 3 LIBERTY ASTHMA QUEST study (NCT02414854) in patients with asthma (≥ 12 years, uncontrolled with moderate to high dose ICS plus ≤ 2 additional controller drugs) with self-reported concomitant AR (63.5% ; n/N=1207/1902) or no concomitant AR evaluated the effect of adding 200 mg or 300 mg of dupilumab or comparable placebo every 2 weeks (q2w) on the annualized rate of severe exacerbations and forced expiratory volume in 1 second (FEV ₁ ). The clinical diagnosis of AR was not recorded.

Baseline characteristics of patients with and without AR were broadly similar. The annualized rate of severe exacerbations was reduced compared with placebo with dupilumab 200 mg q2w (relative risk with AR: 0.606 [95% CI, 0.451–0.814]; P = 0.0009; without AR: 0.406 [95% CI, 0.273 -0.605]; P < 0.0001) with similar results for 300 mg q2w. FEV ₁ improved at week 12 with dupilumab 200 mg q2w (difference in mean LS versus placebo with AR: 0.14 L [95% CI, 0.07–0.21]; P <0.0001; without AR: 0.13 L [95% CI, 0.05–0.22]; P = 0.0023) and persisted until week 52 (both with and without AR: P < 0.0001) with similar results at week 52 for 300mg q2w. The most common adverse event in the dupilumab-treated groups (versus placebo) was an injection site reaction (200 mg/300 mg versus comparable placebo: 15%/18% versus 5%/10%).

Dupilumab provided a significant improvement in FEV ₁ and a year-on-year reduction in severe exacerbations in this population of difficult-to-control asthma with concomitant AR, as well as in patients without concomitant AR.

Population: Patients with and without concomitant AR (AR defined according to CSR). Endpoints: LS-defined mean change from baseline FEV1 at weeks 12 and 52; severe exacerbations during the 52-week treatment period. Security: IT.T.

Example 5 Phase III Trial QUEST - Dupilumab Provides Type 2 Biomarker Suppression in Patients with Asthma with or Without Concomitant Chronic Rhinosinusitis and Nasal Polyposis (CRS+NP) or Chronic Rhinosinusitis without Nasal Polyposis (CRS-NP) in Patients with moderate to severe asthma

In the LIBERTY ASTHMA QUEST phase 3 study (NCT02414854), dupilumab 200/300 mg every 2 weeks compared with comparable placebo provided suppression of type 2 biomarkers in patients with moderate to severe uncontrolled asthma and improved health-related quality of life as measured by SNOT-22, in the difficult-to-treat subgroup with concomitant chronic rhinosinusitis with nasal polyposis (CRS+NP) or (CRSwNP) and with concomitant chronic rhinosinusitis without nasal polyposis (CRS-NP). This retrospective analysis assessed the effect of dupilumab on type 2 biomarkers in this subgroup.

Baseline/change from baseline over time was assessed for the fraction of nitric oxide in exhaled air (FeNO), total IgE, and eotaxin-3. CRS with or without NP was self-assessed in 20.1% (n/N=382/1897) of patients.

Baseline values of FeNO and eotaxin-3 were numerically higher in patients with CRS-NP or CRS+NP than in patients without them. Biomarker suppression was clear in all patients treated with dupilumab by week 12. At week 52, significant biomarker suppression was observed in patients with and without CRS-NP or CRS+NP, as evidenced by the median percentage change from baseline (200 /300 mg dupilumab versus comparable placebo) with CRS-NP or CRS+NP: FeNO 46.2/37.7 vs. 5.5/6.4, IgE 74.8/76.8 vs. 0.0/2 .0, eotaxin-3 47.7/50.9 vs. 1.5/5.4 (all P ≤ 0.0001); without CRS - NP or CRS+NP: FeNO 31.0/35.9 vs. 5.9/10.1, IgE 67.3/67.7 vs. 3.3/6.6, eotaxin-3 31.8/ 37.2 vs. 0.0/0.8 (all P < 0.0001). The most common adverse event with a higher frequency with dupilumab compared with placebo was an injection site reaction (15%/18% versus 5%/10%).

Dupilumab provided suppression of local and systemic type 2 biomarkers in patients with and without CRS+/-NP.

Population: Patients with or without concomitant CRS or NP. Endpoints: percentage change from baseline in total serum IgE, plasma eotaxin-3, and FeNO over a 52-week treatment period. Security: IT.T. Treatment groups: 200 and 300 mg dupilumab q2w and matched placebo.

Example 6 Phase III trial of the QUEST study. Dupilumab reduces severe exacerbations and improves lung function in patients with uncontrolled moderate to severe asthma with late onset

In the phase 3 LIBERTY ASTHMA QUEST study (NCT02414854), this retrospective analysis evaluated the efficacy of dupilumab in patients with late-onset asthma (age >40 years) and a baseline FEV1 ratio after bronchodilator administration/forced vital capacity [FVC] < 0.7 ( suggesting persistent airway obstruction) or ≥ 0.7.

The annualized frequency of severe exacerbations during the 52-week treatment period was assessed using negative binomial regression models. Changes from baseline in pre- and post-bronchodilator FEV1 (L) and pre-bronchodilator FEV1/FVC ratio at weeks 12 and 52 were analyzed using repeated measures mixed effects models.

Dupilumab 200 mg and 300 mg q2w compared with placebo provided a significant reduction in the annualized rate of severe exacerbations in patients with late onset asthma and persistent airway obstruction (68.8% and 75.7%, respectively, P < 0.0001) and in patients without persistent airway obstruction (55.1% and 50.7%, respectively, both P < 0.05) (Fig. 27). At week 12, pre- and post-bronchodilator FEV1 and FEV1/FVC ratio improved in dupilumab-treated patients with late onset asthma and persistent airway obstruction (P < 0.05 vs. placebo, at one or both doses ). Similar improvements were seen at week 52 (200 mg dupilumab q2w P < 0.05 for FEV1 before and after bronchodilator; 300 mg dupilumab q2w FEV1 before bronchodilator P=0.09, FEV1 after bronchodilator P=0.06 ). Patients with late onset asthma without persistent airway obstruction had a more modest improvement compared to placebo in FEV1 before bronchodilator administration at weeks 12 and 52 than patients with persistent airway obstruction (P ≥ 0.05). The most common adverse event in the dupilumab-treated groups compared with comparable placebo was injection site reactions (15%/18% versus 5%/10%).

In patients with late onset asthma with or without persistent airway obstruction, dupilumab provided a significant reduction in the rate of severe exacerbations. In addition, improvements in lung function were observed at weeks 12 and 52 in patients with late-onset asthma and persistent airway obstruction, who generally have worse asthma outcomes than patients without persistent airway obstruction.

Population: ITT population with asthma onset > 40 years and FEV1 after BD/FVC < 0.7; ITT population with age of onset of asthma > 40 years and FEV1 after BD/FVC ≥ 0.7.

Endpoints/visit (data to be included in the abstract: severe exacerbations during the 52-week treatment period; change in mean LS from baseline for FEV1 to BD (l) at weeks 12 and 52; change in mean LS , from baseline for FEV1 after BD (l) at weeks 12 and 52; change in mean LS determined from baseline for FEV1/FVC ratio at weeks 12 and 52; safety.

Treatment groups: dupilumab 200 mg q2w, dupilumab 300 mg q2w and matched placebo groups.

--->

SEQUENCE LIST

<110>

<120> METHODS OF TREATMENT OR PREVENTION OF ASTHMA BY ADMINISTRATION OF IL-4R ANTAGONIST

<130> 601407: SA9-217-4

<140>

<141>

<150>

<151>

<150>

<151>

<160> 8

<170> PatentIn version 3.5

<210> 1

<211> 124

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Artificial sequence description: Synthetic HCVR polypeptide

<400> 1

Glu Val Gln Leu Val Glu Ser Gly Gly Gly Leu Glu Gln Pro Gly Gly

1 5 10 15

Ser Leu Arg Leu Ser Cys Ala Gly Ser Gly Phe Thr Phe Arg Asp Tyr

20 25 30

Ala Met Thr Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val

35 40 45

Ser Ser Ile Ser Gly Ser Gly Gly Asn Thr Tyr Tyr Ala Asp Ser Val

50 55 60

Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Tyr

65 70 75 80

Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys

85 90 95

Ala Lys Asp Arg Leu Ser Ile Thr Ile Arg Pro Arg Tyr Tyr Gly Leu

100 105 110

Asp Val Trp Gly Gln Gly Thr Thr Val Thr Val Ser

115 120

<210> 2

<211> 112

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Artificial sequence description: Synthetic LCVR polypeptide

<400> 2

Asp Ile Val Met Thr Gln Ser Pro Leu Ser Leu Pro Val Thr Pro Gly

1 5 10 15

Glu Pro Ala Ser Ile Ser Cys Arg Ser Ser Gln Ser Leu Leu Tyr Ser

20 25 30

Ile Gly Tyr Asn Tyr Leu Asp Trp Tyr Leu Gln Lys Ser Gly Gln Ser

35 40 45

Pro Gln Leu Leu Ile Tyr Leu Gly Ser Asn Arg Ala Ser Gly Val Pro

50 55 60

Asp Arg Phe Ser Gly Ser Gly Ser Gly Thr Asp Phe Thr Leu Lys Ile

65 70 75 80

Ser Arg Val Glu Ala Glu Asp Val Gly Phe Tyr Tyr Cys Met Gln Ala

85 90 95

Leu Gln Thr Pro Tyr Thr Phe Gly Gln Gly Thr Lys Leu Glu Ile Lys

100 105 110

<210> 3

<211> 8

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Artificial sequence description: Synthetic peptide HCDR1

<400> 3

Gly Phe Thr Phe Arg Asp Tyr Ala

15

<210> 4

<211> 8

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Artificial sequence description: Synthetic peptide HCDR2

<400> 4

Ile Ser Gly Ser Gly Gly Asn Thr

15

<210> 5

<211> 18

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Artificial sequence description: Synthetic peptide HCDR3

<400> 5

Ala Lys Asp Arg Leu Ser Ile Thr Ile Arg Pro Arg Tyr Tyr Gly Leu

1 5 10 15

Asp Val

<210> 6

<211> 11

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Artificial sequence description: Synthetic peptide LCDR1

<400> 6

Gln Ser Leu Leu Tyr Ser Ile Gly Tyr Asn Tyr

1 5 10

<210> 7

<211> 3

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Artificial sequence description: Synthetic peptide LCDR2

<400> 7

Leu Gly Ser

1

<210> 8

<211> 9

<212> PROTEIN

<213> Artificial sequence

<220>

<223> Artificial sequence description: Synthetic peptide LCDR3

<400> 8

Met Gln Ala Leu Gln Thr Pro Tyr Thr

15

<---

Claims (98)

1. The use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) for the treatment of a subject suffering from oral corticosteroid (OCS) dependent asthma, comprising administering to the subject a loading dose of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, wherein maintenance doses are administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and an OCS maintenance phase, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 2. Application according to claim 1, where: a maintenance dose of the antibody or antigen-binding fragment thereof is administered once every two weeks (q2w); or the loading dose is approximately 600 mg of the antibody or antigen-binding fragment thereof; or each maintenance dose of antibody or antigen-binding fragment is approximately 300 mg of antibody or antigen-binding fragment; or maintenance doses of the antibody or antigen-binding fragment thereof are administered for at least 24 weeks; or the first maintenance dose of the antibody or antigen-binding fragment thereof is administered two weeks after the loading dose of the antibody or antigen-binding fragment thereof. 3. Application according to claim 1, where: the duration of the OCS decline phase is approximately 16 weeks; or the subject's OCS use is reduced during the OCS declining phase, optionally where the subject is using 50%, 75%, 90% or less OCS in the maintenance phase compared to the induction phase, or optionally where the subject's OCS use is reduced to about 5 mg/day or less in the maintenance phase, or optionally where OCS administration is reduced and/or eliminated in the maintenance phase; or the subject's use of OCS is optimized prior to treatment with the antibody or antigen-binding fragment thereof. 4. The use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in the treatment of a subject suffering from oral corticosteroid (OCS) dependent asthma, comprising: administering to the subject a loading dose of approximately 600 mg of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, where each maintenance dose is approximately 300 mg of the antibody or antigen-binding fragment thereof, wherein the maintenance doses are administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and a maintenance phase, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 5. The use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in reducing the annualized rate of severe exacerbations in a subject suffering from oral corticosteroid (OCS) dependent asthma, comprising administering to the subject a q2w antibody or its antigen-binding fragment, wherein the antibody, or antigen-binding fragment thereof, is administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and an OCS maintenance phase, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 6. Use according to claim 5 wherein the dose is about 200 mg q2w or about 300 mg q2w. 7. Use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in improving FEV ₁ in a subject suffering from oral corticosteroid (OCS) dependent asthma, comprising administering to the q2w subject the antibody or antigen-binding fragment thereof , whereby the subject has an improvement in FEV ₁ at week 4, week 12, or week 24 after administration of the antibody or antigen-binding fragment, wherein the antibody, or antigen-binding fragment thereof, is administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and an OCS maintenance phase, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 8. Use according to claim 7 wherein the dose is about 200 mg q2w or about 300 mg q2w. 9. Use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in reducing or eliminating oral corticosteroid (OCS) use in a subject suffering from oral corticosteroid (OCS) dependent asthma, the method comprising administering to the subject a loading dose of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, where a reduction in OCS use of at least 50% is achieved at week 24 post loading dose, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 10. Application according to claim 9, where: OCS use is reduced to less than 5 mg per day at week 24 post-loading dose; or dependence on the use of OCS is substantially eliminated after some period of time after the administration of the loading dose, optionally, where the time period is 40 weeks, 45 weeks, 50 weeks, 52 weeks or more; or a maintenance dose of the antibody or antigen-binding fragment thereof is administered once every two weeks (q2w); or the loading dose is approximately 600 mg of the antibody or antigen-binding fragment thereof, optionally wherein each maintenance dose of the antibody or antigen-binding fragment thereof is approximately 300 mg of the antibody or antigen-binding fragment thereof; or maintenance doses of the antibody or antigen-binding fragment thereof are administered for at least 24 weeks; or the first maintenance dose of the antibody or antigen-binding fragment thereof is administered two weeks after the loading dose of the antibody or antigen-binding fragment thereof; or a reduction in the use of OCS by at least 75% is achieved; or a reduction in the use of OCS by at least 90% is achieved. 11. The use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in the treatment of a subject suffering from moderate to severe oral corticosteroid (OCS) dependent asthma, comprising administering to the subject a loading dose of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof is administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and an OCS maintenance phase, wherein the loading dose and one or more maintenance doses are administered as adjunctive maintenance therapy for asthma, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 12. The use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in improving asthma control in a subject suffering from oral corticosteroid-dependent asthma, comprising administering to the subject a loading dose of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and one or more maintenance doses are administered as adjunctive maintenance therapy for asthma, and wherein the antibody, or antigen-binding fragment thereof, is administered during a treatment phase comprising an induction phase, an oral corticosteroid (OCS) reduction phase, and an OCS maintenance phase, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 13. The use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in the treatment of a subject suffering from oral corticosteroid (OCS) dependent asthma and associated moderate to severe atopic dermatitis, comprising administering to the subject a loading dose of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and one or more maintenance doses are administered as adjunctive maintenance therapy for asthma, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 14. The use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in the treatment of a subject suffering from oral corticosteroid (OCS) dependent asthma, where the onset of asthma occurred when the subject was over 40 years of age, including administering to the subject a loading dose of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and one or more maintenance doses are administered as adjunctive maintenance therapy for asthma, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 15. The use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in the treatment of a subject suffering from oral corticosteroid (OCS) dependent asthma and concomitant allergic rhinitis, comprising administering to the subject a loading dose of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and one or more maintenance doses are administered as adjunctive maintenance therapy for asthma, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 16. Use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in the treatment of a subject suffering from oral corticosteroid (OCS) dependent asthma and one or both of concomitant chronic rhinosinusitis and nasal polyposis, comprising: administering to the subject a loading dose of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and one or more maintenance doses are administered as adjunctive maintenance therapy for asthma, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 17. Use of an antibody or antigen-binding fragment thereof that specifically binds to the interleukin-4 receptor (IL-4R) in improving the quality of life associated with allergic rhinitis in a subject suffering from oral corticosteroid (OCS) dependent asthma and concomitant allergic rhinitis, including: administering to the subject a loading dose of the antibody or antigen-binding fragment thereof; And administering to the subject one or more maintenance doses of the antibody or antigen-binding fragment thereof, wherein the loading dose and one or more maintenance doses are administered as adjunctive maintenance therapy for asthma, and wherein the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining region (CDR) sequences comprising SEQ ID NOs: 3, 4 and 5, respectively, and three light chain CDR sequences comprising SEQ ID NOs: 6, 7 and 8, respectively. 18. Use according to any one of claims 1 to 17, wherein the antibody or antigen-binding fragment thereof comprises an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and an LCVR comprising the amino acid sequence of SEQ ID NO: 2. 19. Use according to any one of claims 13-17, where: loading dose is 400 mg, maintenance dose is 200 mg and maintenance doses are administered biweekly; or the loading dose is 600 mg, the maintenance dose is 300 mg, and the maintenance doses are administered biweekly. 20. Use according to any one of claims 1 to 17, where: improve asthma symptoms in the morning and evening; or the loading dose is excluded; or the subject is an adult; or the subject is a teenager; or age of the subject 12 years and older; or OCS is prednisone or prednisolone; or improved health-related quality of life; or OCS-dependent asthma is severe asthma dependent on oral corticosteroids. 21. Use according to any one of claims 1-17, where: the number of eosinophils in the blood of the subject is less than about 150 cells/µl; or the number of eosinophils in the blood of the subject is greater than or equal to about 150 cells/µl; or the number of eosinophils in the blood of the subject is more than about 300 cells/µl; or the subject has a FeNO level greater than or equal to about 25 ppb or about 50 ppb; or the subject demonstrates at least a 10% or 25% reduction in a biomarker selected from the group consisting of FeNO, eotaxin-3, total IgE, periostin, and thymus-regulated activating chemokine (TARC) at week 4, week 12, or week 24 after introduction of antibodies to IL-4R or its fragment.

Images