WO2025242619A1 - Treatment for mucus plugging - Google Patents

Abstract

Provided herein are methods for reducing mucus plugging in a patient suffering from chronic lung disease. The methods comprise administering to the patient an antibody which binds IL-33 and inhibits IL-33-mediated activation of EGFR/RAGE. The antibody which binds IL-33 may be tozorakimab.

Description

IL33-460-PCT01-NP

TREATMENT FOR MUCUS PLUGGING

CROSS-REFERENCE TO RELATED PATENT APPLICATION

This specification claims the benefit of priority to European Patent Application 24176882.9 (filed 20 May 2024), European Patent Application 24185132.8 (filed 27 June 2024) and European Patent Application EP24216954.8 (filed 2 December 2024). The entire text of the above-referenced patent applications are incorporated by reference into this specification.

FIELD

Provided herein are methods for reducing mucus plugging in the lungs of a patient.

BACKGROUND

A common pathological feature of chronic lung diseases is the obstruction of the airways of the lungs by accumulated mucus. These mucoid obstructions are referred to as mucus plugs, and form as a result of mucus hypersecretion, mucus hyperviscosity and/or impaired mucus clearance. The presence of mucus plugs is associated with airflow obstruction and worse health-related quality of life in multiple respiratory diseases (Tamura et al., Allergy, Asthma and Immunology Research 14(2): 196-209, 2022, Okajima et al., CHEST 2020; 158(1 ): 121 -130), and in COPD their presence in multiple lung segments is associated with an increased risk of death from respiratory disease (Diaz et al., JAMA 329(21):1832-1839, 2023; Mettler et al., American Journal of Respiratory and Critical Care Medicine 209: A5122, 2024).

Current treatments for mucus plugging primarily focus on improving the physical properties of the mucus, to enable normal clearance of the mucus from the lungs. This is achieved by a combination of mucosal hydration and mucolysis (i.e. the reduction of intermucin disulphide bonds), which together reduce mucus viscosity (Boucher, New England Journal of Medicine 380(20): 1941-1953, 2019). However, there is a pressing need for more effective treatments for mucus plugging, to improve outcomes for sufferers of chronic lung diseases, and to reduce the burden on health systems of lung disease patients.

A number of new, biologic drugs are currently under investigation for treatment of chronic lung diseases, including tozorakimab.

Tozorakimab is a human antibody against IL-33. IL-33 is a pleiotropic nuclear alarmin cytokine from the IL-1 superfamily, which has recently been identified as a putative factor in certain chronic airway diseases, including COPD. A full-length, reduced form of IL-33 (I L-33^red) is released from damaged epithelial and endothelial barrier cells and alerts the immune system to tissue damage. IL-33 drives pulmonary inflammation through its receptor complex ST2/IL1 RAcP via the NF-KB pathway, which is expressed by several inflammatory cell types including mast cells, type 1 and 2 innate lymphoid cells, macrophages and endothelial cells. The IL-33/ST2 signalling pathway leads to production of inflammatory cytokines such as IL-6 and granulocyte-macrophage colony-stimulating factor by these cell types (Chakerian et al., Journal of Immunology 179(4): 2552-2555, 2007).

Following cellular release, IL-33 is rapidly oxidised to form I L-33^OX, in which two disulphide bridges are formed causing an extensive conformational change in the cytokine (Cohen et al., Nature Communications 6: 8327, 2015). I L-33^OX cannot bind the ST2 receptor, but recently an ST2-independent IL-33 signalling pathway has been identified. I L-33^OX binds a complex of RAGE/EGFR to signal via the JNK pathway, driving epithelial remodelling and dysfunction, including mucus hypersecretion and defective damage repair (Strickson et al., European Respiratory Journal 62: 2202210, 2023).

Tozorakimab has been found to be capable of blocking both IL-33 signalling pathways. Tozorakimab binds I L-33^red with high affinity, blocking its binding to the ST2 receptor. Tozorakimab has also been found to inhibit oxidation of I L-33^red, indirectly inhibiting EGFR/RAGE activation (England et al., Scientific Reports 13: 9825, 2023).

Tozorakimab is currently under investigation for treatment of COPD (WO 2023/025932; NCT06040086). Another new biologic drug under investigation for treatment of COPD is the anti-IL-4Ra antibody dupilimab (Bhatt et al., New England Journal of Medicine 389(3): 205-214, 2023). However, as yet no biologic drug has been shown to reduce mucus plugging.

SUMMARY

The methods provided herein are based on the finding, set out in the Examples below, that tozorakimab reduces mucus plugging in patients suffering from chronic lung disease.

Without being bound by theory, it is believed that this effect may be primarily mediated by blockade of the EGFR/RAGE pathway.

Thus in a first aspect, provided herein is a method of reducing mucus plugging in a patient in need thereof, the method comprising administering to the patient an antibody or antigen-binding fragment thereof which binds IL-33 and inhibits IL-33-mediated activation of EGFR/RAGE.

In a related aspect, provided herein is an anti-IL-33 antibody or antigen-binding fragment thereof for use in a method of reducing mucus plugging in a patient, the method comprising administering to the patient the anti-IL-33 antibody or antigen-binding fragment thereof, wherein the antibody or fragment inhibits IL-33-mediated activation of EGFR/RAGE.

In a further related aspect, provided herein is the use of an anti-IL-33 antibody or antigen-binding fragment thereof in the manufacture of a medicament for treating mucus plugging in a patient, wherein the antibody or fragment thereof inhibits IL-33-mediated activation of EGFR/RAGE.

In a further related aspect, provided herein is the use of an anti-IL-33 antibody or antigen-binding fragment thereof to treat mucus plugging in a patient, wherein the antibody or fragment thereof inhibits IL-33-mediated activation of EGFR/RAGE.

In a further related aspect, provided herein is a pharmaceutical composition comprising an anti-IL-33 antibody or antigen-binding fragment thereof for use in a method of reducing mucus plugging in a patient, wherein the antibody or fragment thereof inhibits IL-33-mediated activation of EGFR/RAGE.

In some embodiments of the methods and related aspects, the method further comprises:

(i) determining the level of mucus plugging in the patient’s lungs prior to treatment with the anti-IL-33 antibody or fragment thereof;

(ii) determining the level of mucus plugging in the patient’s lungs after at least one dose of the anti-IL-33 antibody or fragment thereof; and

(iii) comparing the level of mucus plugging in the patient’s lungs prior to treatment with the level after at least one dose of the anti-IL-33 antibody or fragment thereof, to determine the reduction in the level of mucus plugging.

Generally, the level of mucus plugging in the patient’s lungs is determined by a scan. Thus in these embodiments the method may comprise:

(i) a baseline scan of the patient’s lungs to determine the level of mucus plugging prior to treatment with the anti-IL-33 antibody or fragment thereof;

(ii) at least one follow-up scan of the patient’s lungs to determine the level of mucus plugging after at least one dose of the anti-IL-33 antibody or fragment thereof; and

(iii) comparing a follow-up scan with the baseline scan to determine the reduction in the level of mucus plugging.

In a second aspect, provided herein is a method of diagnosing and treating mucus plugging in a patient, the method comprising determining whether mucus plugs are present in the patient’s lungs, and where mucus plugs are present, administering to the patient an antibody or antigen-binding fragment thereof which binds IL-33 and inhibits IL-33-mediated activation of EGFR/RAGE.

In embodiments, this aspect comprises scanning the chest of the patient, thereby identifying whether mucus plugs are present in the patient’s lungs; and where mucus plugs are present, administering to the patient an antibody or antigenbinding fragment thereof which binds IL-33 and inhibits IL-33-mediated activation of EGFR/RAGE. In general, the antibody or fragment thereof used herein also inhibits IL-33 mediated activation of ST2/IL1 RAcP. That is to say, generally the anti-IL-33 antibody binds IL-33 and inhibits IL-33 mediated activation of EGFR/RAGE and IL-33 mediated activation of ST2/IL1 RAcP.

In some embodiments of the methods and related aspects, the patient is a human, in particular a human adult.

In some embodiments of the methods and related aspects, the patient has COPD, bronchiectasis or asthma.

In some embodiments of the methods and related aspects, the patient has COPD and chronic bronchitis.

In some embodiments of the methods and related aspects, prior to treatment, the patient has at least one mucus plug in at least 3 or at least 4 lung segments.

In some embodiments of the methods and related aspects, treatment with the anti- IL-33 antibody reduces the number of lung segments comprising a mucus plug by at least 1 or at least 2.

In some embodiments of the methods and related aspects, the reduction in mucus plugging is associated with an improvement in lung function.

In some embodiments of the methods and related aspects, the patient is receiving an inhaled maintenance therapy comprising a long-acting Beta 2 agonist (LABA), a long-acting muscarinic receptor antagonist (LAMA), and/or an inhaled corticosteroid (ICS).

In some embodiments of the methods and related aspects, the patient is a current smoker or a former smoker.

In some embodiments of the methods and related aspects, prior to treatment, the patient has a post-bronchodilator forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio (post-bronchodilator (post-BD)-FEV1/FVC) of less than 0.70.

In some embodiments of the methods and related aspects, prior to treatment, the patient has a post-BD FEV1 between 20 % and 80 % of predicted normal value.

In some embodiments of the methods and related aspects, the antibody or fragment thereof comprises:

(a) a heavy chain variable region comprising a VHCDR1 comprising the sequence of SEQ ID NO: 1, a VHCDR2 comprising the sequence of SEQ ID NO: 2, and a VHCDR3 comprising the sequence of SEQ ID NO: 3; and

(b) a light chain variable region comprising a VLCDR1 comprising the sequence of SEQ ID NO: 4, a VLCDR2 comprising the sequence of SEQ ID NO: 5, and a VLCDR3 comprising the sequence of SEQ ID NO: 6. In some embodiments of the methods and related aspects, the antibody or fragment thereof comprises a heavy chain variable region comprising the sequence of SEQ ID NO: 7, or an amino acid sequence with at least 80 % sequence identity thereto; and a light chain variable region comprising the sequence of SEQ ID NO: 8, or an amino acid sequence with at least 80 % sequence identity thereto.

In some embodiments of the methods and related aspects, the antibody or fragment thereof is human.

In some embodiments of the methods and related aspects, the antibody or fragment thereof is tozorakimab.

In some embodiments of the methods and related aspects, the anti-IL-33 antibody or antigen-binding fragment thereof is administered to the subject subcutaneously.

In some embodiments of the methods and related aspects, the anti-IL-33 antibody or antigen-binding fragment thereof (particularly tozorakimab) is administered to the patient at a dose of about 200 mg to about 800 mg every 1 to 4 weeks.

In some embodiments of the methods and related aspects, the anti-IL-33 antibody or antigen-binding fragment thereof is administered to the patient over a course of therapy lasting at least 6 months.

FIGURE LEGENDS

Figure 1 shows the change in mucus plugging score from baseline to week 28 for patients on the imaging sub-study of the FRONTIER 4 clinical trial. The figures shows the results for patients receiving tozorakimab (left panel) and placebo (right panel). Each line may represent more than one patient (annotated numbers indicate the number of patients at each data point). Nominal one-sided p=0.0312. Change from baseline in mucus plugging score reduction was compared between treatment groups using a Van-Elteren test stratified for baseline mucus score subgroup (zero [0], low [1—3] and high [4+]).

Figure 2 plots the change in mucus plugging score from baseline to week 28 against the change in pre-BD FVC from baseline to week 28. Regression lines for the tozorakimab treated group (solid line) and placebo treated group (dashed line) are calculated and shown. The graph shows a correlation of the greater the reduction in mucus plugging, the greater the improvement in FVC.

Figure 3 plots the change in mucus plugging score from baseline to week 28 against the change in pre-BD FEV1 from baseline to week 28. Regression lines for the tozorakimab treated group (solid line) and placebo treated group (dashed line) are calculated and shown. A slight but statistically insignificant correlation is seen between a reduction in mucus plugging and the increase in FEV1. Figure 4 shows the production of the mucin MLIC5AC by healthy nasal epithelial cells and nasal epithelial cells from non-cystic fibrosis bronchiectasis (NCFBE) patients which were either untreated or treated with tozorakimab, itepekimab or an IgG 1 isotype control. MLIC5AC levels were measured in apical washes from 3D nasal airway epithelium cultures by immunoassay. Individual datapoints are shown (n=4 individual healthy control donors and n=7 individual NCFBE donors), error bars indicate SEM (standard error of the mean).

* = p < 0.05; ** = p < 0.005; *** = p < 0.001 (non-parametric Kruskal-Wallis test with multiple comparisons). NS = not significant.

DETAILED DESCRIPTION

The term "about" or "approximately" means an acceptable error for a particular value as determined by one of ordinary skill in the art, which depends in part on how the value is measured or determined. In certain embodiments, the term "about" or "approximately" means within 1, 2, 3, or 4 standard deviations. In certain embodiments, the term "about" or "approximately" means within 30%, 25%, 20%, 15%, 1 0%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, or 0.05% of a given value or range. Whenever the term "about" or "approximately" precedes the first numerical value in a series of two or more numerical values, it is understood that the term "about" or "approximately" applies to each one of the numerical values in that series. It is to be understood that whenever the term "about" or "approximately" precedes a numerical value, the exact numerical value is explicitly disclosed.

It is to be noted that the term "a" or "an" entity refers to one or more of that entity; for example, "an antibody," is understood to represent one or more antibodies. As such, the terms “a” (or “an”), “one or more”, and “at least one” can be used interchangeably herein.

Furthermore, “and/or” where used herein is to be taken as specific disclosure of each of the two specified features or components with or without the other. Thus, the term “and/or” as used in a phrase such as “A and/or B” herein is intended to include “A and B”, “A or B”, “A” (alone) and “B” (alone). Likewise, the term “and/or” as used in a phrase such as “A, B and/or C” is intended to encompass each of the following aspects: A, B and C; A, B or C; A or C; A or B; B or C; A and C; A and B; B and C; A (alone); B (alone); and C (alone).

It is understood that wherever aspects are described herein with the language “comprising”, otherwise analogous aspects described in terms of “consisting of” and/or “consisting essentially of” are also provided. Herein, the terms “comprises”, “comprising”, “containing” and “having” and the like can mean “includes”, “including” and the like; “consisting essentially of” or “consists essentially of” are open-ended, allowing for the presence of more than that which is recited so long as basic or novel characteristics of that which is recited is not changed by the presence of more than that which is recited, but excludes prior art aspects.

Units, prefixes, and symbols are denoted in their Systeme International de Unites (SI) accepted form. Numeric ranges are inclusive of the numbers defining the range.

Unless otherwise indicated, amino acid sequences are written left to right in amino to carboxy orientation.

Unless defined otherwise, technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the present methods and related aspects pertain. For example, the Concise Dictionary of Biomedicine and Molecular Biology, Juo, Pei-Show, 2nd ed., 2002, CRC Press; The Dictionary of Cell and Molecular Biology, 3rd ed., 1999, Academic Press; and the Oxford Dictionary of Biochemistry and Molecular Biology, Revised, 2000, Oxford University Press, provide one of skill with a general dictionary of many of the terms used herein.

Throughout, references to “an anti-IL-33 antibody” encompass antigen-binding fragments of such antibodies, except where the context makes clear that a full-length antibody is meant.

Mucus Plugging

The present methods and associated aspects relate to treating mucus plugging in patients in need of such treatment, i.e. patients with mucus plugs in their lungs. The treatment is performed in order to reduce mucus plugging in the patient (i.e. to reduce the number of mucus plugs the patient has), and thus the methods and associated aspects may be referred to as being for reducing mucus plugging in patients. The terms “treating mucus plugging” and “reducing mucus plugging” as used herein are interchangeable.

Certain diseases of the respiratory tract cause the accumulation of mucus in the airways of the lungs. Commonly, the accumulation of mucus in this manner is associated with mucus hypersecretion (where too much mucus is produced), mucus hyperviscosity (where the mucus produced has an abnormally thick and viscous consistency) and/or deficient mucus clearance, e.g. due to defects in the cilia. Where the mucus accumulates to such an extent as to form a blockage in an airway (which may be partial or total), this is referred to as a mucus plug. Mucus plugs may form in a patient’s bronchi or a patient’s bronchioles, and can have pathological consequences including reduced lung function, recurrent chest infections or in severe cases atelectasis (partial or complete lung collapse).

Mucus plugs may be visualised by X-ray or, more commonly, computed tomography (CT) scanning. On a CT scan, a mucus plug may appear as an opacity that occludes the lumen of an airway, with a visibly patent and air-containing lumen proximal and distal to the plug. In some embodiments, a mucus plug as defined herein completely occludes the airway in which it is present, such that the plug forms a complete blockage in the airway which air cannot pass. In other embodiments, a mucus plug as defined herein partially occludes the airway in which it is present. For instance, a mucus plug may occlude the airway in which it is present by at least 50, 60, 70, 80 or 90 % (i.e. the plug may reduce the cross-sectional area of the airway, through which air can travel, by at least 50, 60, 70, 80 or 90 %).

Diagnosis of Mucus Plugging

Diagnosis and/or quantification of mucus plugging may be made by any method known in the art. Diagnosis of mucus plugging can be made by a chest scan, e.g. a chest CT scan, as described above. In the method of diagnosing and treating mucus plugging in a patient, the patient is initially a subject suspected of suffering from mucus plugging, e.g. due to respiratory symptoms they are suffering from or due to a diagnosis of another respiratory condition known to be associated with mucus plugging. Whether the patient has mucus plugs in their lungs is determined by a suitable diagnostic technique. Generally, the patient is subjected to a scan to identify whether mucus plugging is present in their lungs. Where mucus plugging is identified in the patient’s lungs (i.e. where the patient is diagnosed with mucus plugging), the patient is then treated for mucus plugging by administration of an anti- IL-33 antibody or fragment thereof, as set out herein.

Patients

The patient treated according to the present methods is a subject suffering from mucus plugging, i.e. they have at least one mucus plug in their lungs. Generally the patient is a human. Most commonly, the patient is an adult human, though children may also be treated according to the methods provided herein.

As defined herein, a person has 18 lung segments: 10 in the right lung and 8 in the left lung, in line with Netter’s bronchial anatomy nomenclature (Netter FH, Atlas of Human Anatomy: Classical Regional Approach, 8^th Edition, Saunders (Elsevier), Philadelphia, PA, USA, 2023). The right lung segments are the: apical segment (RB1 ), posterior segment (RB2) and anterior segment (RB3) of the upper lobe; lateral segment (RB4) and medial segment (RB5) of the middle lobe; and the superior segment (RB6), medial segment (RB7), anterior segment (RB8), lateral segment (RB9) and posterior segment (RB10) of the lower lobe. The left lung segments are the: apicoposterior segment (LB1/2), anterior segment (LB3), superior lingular segment (LB4) and inferior lingular segment (LB5) of the upper lobe; and the superior segment (LB6), anteromedial segment (LB7/8), lateral segment (LB9) and posterior segment (LB10) of the lower lobe. The notations in brackets (‘RB1’ etc.) refer to the Boyden classification of bronchi (Boyden, Diseases of the Chest 23(3): 266-269, 1953). As noted above, the patient treated according to the present methods has at least one mucus plug. The mucus plug may be in either lung, in any lobe or segment. In some embodiments, the patient has multiple mucus plugs (i.e. at least 2 mucus plugs). In this case, the mucus plugs may be in the same lung segment, in multiple segments of the same lobe, in multiple lobes of the same lung, or in both lungs.

The patient treated according to the present methods may have, prior to treatment, at least one mucus plug in at least three lung segments. That is to say, the patient may have mucus plugs in at least 3 lung segments. And each lung segment containing a mucus plug, may contain one or more mucus plugs, e.g. 1 , 2, 3 or more mucus plugs. It has previously been found that patients with mucus plugs in at least 3 lung segments are at increased risk of death from respiratory disease than patients with less extensive mucus plugging (Diaz et al., supra, Mettler et al., supra) and so such patients may particularly benefit from the treatments provided herein. In such embodiments, the lung segments containing mucus plugs may all be in the same lobe of a lung, or in two or more different lung lobes. The segments containing mucus plugs may be in the same lung, or spread across both lungs.

In some embodiments, the patient treated according to the present methods has, prior to treatment, at least 1 mucus plug in at least 4 lung segments. In the Examples below, the presence of mucus plugs in at least 4 lung segments is defined as having high severity mucus plugging. For example, the patient may have at least 1 mucus plug in at least 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, 16 or 17 lung segments. The patient may have at least 1 mucus plug in all 18 lung segments.

In some embodiments, the determination of mucus plugging (e.g. counting of the number of lung segments comprising mucus plugs) excludes assessment of the peripheral airways within 2 cm of the diaphragmatic pleura and costal pleura. The narrowness of these airways can make it difficult to determine whether they are occluded by a mucus plug.

The mucus plugging in the patient’s lungs may have been diagnosed using standard methods in the art, e.g. a chest scan, particularly a chest CT scan.

The mucus plugging may have any underlying cause. Mucus plugs generally form in the context of chronic lung diseases, and so the patient treated according to the methods provided herein may have a chronic lung disease.

In some embodiments, the patient has chronic obstructive pulmonary disease (COPD). In such cases, the mucus plugs may be associated with (i.e. caused by) the COPD. Thus in some embodiments, provided herein are methods for reducing mucus plugging caused by COPD, or methods for reducing mucus plugging associated with COPD. COPD is characterized by airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases, and influenced by host factors including abnormal lung development. The abnormalities of the lungs result in reduced airflow through the airways and progressive loss of lung function. COPD is associated with increased mucus (sputum) production, which can lead to the formation of mucus plugs.

In some embodiments, the patient with COPD has COPD with chronic bronchitis (or COPD associated with chronic bronchitis). Bronchitis is inflammation of the bronchi. A patient with chronic bronchitis may have suffered from the symptoms of bronchitis (cough, production of mucus/sputum, fatigue, shortness of breath, fever, chills, and/or chest discomfort) for a period of more than 8 weeks, more than 16 weeks, more than 32 weeks, or more than 52 weeks.

In some embodiments, the patient does not have COPD.

In some embodiments, the patient has bronchiectasis. In such cases, the mucus plugs may be associated with (i.e. caused by) the bronchiectasis. Thus in some embodiments, provided herein are methods for reducing mucus plugging caused by bronchiectasis, or methods for reducing mucus plugging associated with bronchiectasis. Bronchiectasis is a chronic, and frequently progressive, lung condition characterized by symptoms including chronic (i.e. persistent) cough, sputum production (which can result in mucus plugs), shortness of breath, haemoptysis (i.e. coughing up blood), wheezing and chest pain. Bronchiectasis is caused by abnormal and permanent dilation of the bronchi, commonly a result of an infection, an allergic reaction or an immunodeficiency.

Mucus plugging may occur in bronchiectasis, particularly plugging of the bronchi. Mucus plugging may be visualised by CT scanning. The treatments provided herein may reduce mucus plugging. In some embodiments, the treatment may reduce or entirely remove existing mucus plugging from one or more bronchi. In some embodiments, the treatment may prevent the development of mucus plugging, or may prevent existing mucus plugging from worsening (e.g. the treatment may cause stabilisation of mucus plugging). Reduction, stabilisation or prevention of mucus plugging may be visualised by CT scanning.

In some embodiments, the patient does not have bronchiectasis.

In some embodiments, the patient has asthma. In such cases, the mucus plugs may be associated with (i.e. caused by) the asthma. Thus in some embodiments, provided herein are methods for reducing mucus plugging caused by asthma, or methods for reducing mucus plugging associated with asthma. Asthma is an inflammatory condition of the lungs thought to be caused by a combination of genetic and environmental factors. Asthma symptoms can include wheezing, coughing and excess mucus production, which can result in the formation of mucus plugs.

In some embodiments, the patient has more than one chronic lung disease. For example, the patient may have asthma and bronchiectasis, or COPD and bronchiectasis, or asthma and COPD. In some embodiments, the patient is a current smoker or former smoker. A “former smoker” may be defined as a patient who is not smoking at the onset of therapy, ceased smoking a minimum of 6 months prior to the beginning of therapy and has an intention to stop smoking permanently. In some embodiments, the patient to be treated has a smoking history of 10 or more pack-years. Pack-years are calculated as the average number of cigarettes per day x number of years 120. For example, 1 pack-year = 20 cigarettes smoked per day for 1 year or 10 cigarettes per day for 2 years. In particular, the patient may be a current or former smoker, as described above, with COPD, for example COPD with chronic bronchitis.

In some embodiments, the patient is receiving an inhaled maintenance therapy for a respiratory condition, such as COPD, bronchiectasis or asthma. The maintenance therapy may comprise a long-acting Beta-2 adrenergic receptor agonist (LABA), a long-acting muscarinic receptor antagonist (LAMA), and/or an inhaled corticosteroid (ICS). Such maintenance therapies may in particular be used for treatment of COPD, but may also be used for treatment of other lung conditions.

As used herein, the term “long-acting Beta-2 adrenergic receptor agonist” refers to any beta-adrenoceptor agonist with a duration of action of approximately 12 hours or more. This is in contrast to short-acting beta agonists (SABA) such as salbutamol, which have a duration of action of approximately 4-6 hours. Exemplary LABAs include arformoterol, bambuterol, clenbuterol, formoterol, salmeterol, protokylol. A LABA may be an “ultra-LABA” with a duration of action of 24 hours or more, for example indacaterol, olodaterol, or vilanterol. A LABA may be administered through any suitable route, for example through use of a nebuliser, inhaler, or vaporiser.

As used herein, the term “long-acting muscarinic receptor antagonist” refers to anticholinergic agents that block the activity of the muscarinic acetylcholine receptor. Exemplary LAMAs include tiotropium bromide, glycopyrronium bromide and aclidinium bromide. A LAMA may be administered through any suitable route, for example through use of a nebuliser, inhaler, or vaporiser.

As used herein, the term “inhaled corticosteroid” refers to any corticosteroid treatment administered via a nebuliser, inhaler or vaporiser. Exemplary ICSs include fluticasone propionate, budesonide, and/or beclometasone dipropionate.

In some embodiments the inhaled maintenance therapy is a dual therapy (i.e. comprising two drugs). A dual therapy may comprise e.g. a LABA and a LAMA or an ICS and a LABA. In other embodiments, the inhaled maintenance therapy is a triple therapy (i.e. comprising three drugs). A triple therapy may comprise a LABA, a LAMA and an ICS.

The patient treated herein may have reduced lung function due to a chronic lung disease, to which mucus plugging may contribute. In some embodiments, prior to treatment, the patient has a post-bronchodilator (post- BD) forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio (post- BD-FEV1/FVC) of less than 0.70.

FEV1 is the maximum volume of air that an individual can forcibly expel during the first second following maximum inhalation. It is a measure of lung function, focussed on the rate of airflow through the lung’s of a patient. Conveniently, FEV1 can be measured by spirometry, as is well known in the art. The higher the FEV1 value, the greater the level of airflow through the patient’s lungs; conversely, the lower the FEV1 value, the worse the airflow through the patient’s lungs.

FVC is the total volume of air which can be forcibly exhaled after maximum inhalation, and is another measure of lung function. FVC may also be measured by spirometry, as is well known in the art.

By “post-bronchodilator” FEV1/FVC is meant that the FEV1 and FVC are measured after administration to the patient of a bronchodilator, which is typically administered via an inhaler or a nebuliser. Suitable bronchodilators include albuterol and salbutamol.

The FEV1/FVC ratio is also known as the modified Tiffeneau-Pinelli index, and represents the proportion of a person's vital capacity that they are able to expire in the first second of forced expiration. A healthy person has an FEV1/FVC ratio of about 0.75. A ratio of below 0.70 is deemed diagnostic for an obstructive lung condition, with values of less than 0.6 indicating at least a moderate degree of obstruction and values of less than 0.5 indicating severe obstruction. In some embodiments, the patient has a post-bronchodilator FEV1/FVC ratio of less than 0.7, 0.6, 0.5, 0.4 or 0.3 prior to commencing anti-IL-33 treatment.

In some embodiments, prior to treatment, the patient has a post-BD FEV1 of 80 % or less of the predicted normal value (i.e. the value expected for a healthy patient of that age, sex and size). Predicted normal FEV1 values can be obtained from the Global Lung Function Initiative. An FEV1 less than 80 % of the predicted normal value is considered subnormal. In some cases, prior to treatment, the patient has a post-BD FEV1 of 70, 60, 50, 40, 30 or 20 % or less of the predicted normal value. For example, the patient may have a post-BD FEV1 in the range of 20 to 80 % of normal value, e.g. 20-80 %, 30-80, 40-80 %, 50-80 %, 60-80 %, 20-70 %, 30-70 %, 40-70 %, 50-70 %, 20-60 %, 30-60 %, 40-60 %, 20-50 %, 30-50 % or 20-40 %.

Treating Mucus Plugging

The methods provided herein comprise treating mucus plugging in a patient using an anti- IL-33 antibody. Such treatment of mucus plugging may cause an improvement in the patient’s condition. By “improvement in the patient’s condition” is meant a reduction in mucus plugging.

Thus the methods provided herein may result in a reduction in the number of mucus plugs in a patient’s lungs. In some embodiments the treatments provided herein reduce the number of mucus plugs in a patient’s lungs by at least 1 , 2, 3, 4, 5, 6, 7, 8, 9 or 10.

Advantageously, the methods provided herein may result in the complete clearance of mucus plugs from one or more lung segments. In some embodiments the treatments provided herein reduce the number of the patient’s lung segments comprising a mucus plug by at least 1. In some embodiments the treatments provided herein reduce the number of the patient’s lung segments comprising a mucus plug by at least 2. In some embodiments the treatments provided herein reduce the number of the patient’s lung segments comprising a mucus plug by at least 3, 4, 5, 6, 7, 8, 9 or 10. In some embodiments, the methods provided herein result in the complete clearance of mucus plugs from the lungs, such that following anti-IL-33 treatment the patient has no mucus plugs remaining.

As shown in the Examples, the greater the number of affected segments in a patient, the greater the average reduction in mucus plugging seen. Thus in some embodiments, prior to treatment, the patient has at least 1 mucus plug in at least 4 lung segments, and the treatment provided herein reduces the number of the patient’s lung segments comprising a mucus plug by at least 2.

A reduction in the number of mucus plugs in a patient’s lungs can be calculated as the difference between the number of plugs present in the patient’s lungs after beginning anti-IL-33 treatment compared with the number of plugs present in the patient’s lungs before anti-IL-33 treatment. Equivalently, a reduction in the number of a patient’s lung segments containing a mucus plug can be calculated as the difference between the number of lung segments containing a plug after beginning anti-IL-33 treatment compared with the number of lung segments containing a plug before anti-IL-33 treatment.

The reduction in mucus plugging may be observed at any timepoint following commencement of treatment with the anti-IL-33 antibody. In some cases the reduction in mucus plugging is observed at week 4, 8, 12, 24, 28, 32, 36 or 52 following commencement of the anti-IL-33 treatment. That is to say, the reduction in mucus plugging may occur within 4, 8, 12, 24, 28, 32, 36 or 52 weeks of the first administration of the anti-IL-33 antibody.

In some embodiments, the reduction in mucus plugging is a continuous process, such that over time the number of mucus plugs in the patient’s lungs gradually reduces.

In some embodiments, the reduction in mucus plugging is associated with an improvement in lung function. By “associated with” an improvement in lung function is meant that, following commencement of anti-IL-33 treatment, both a reduction in mucus plugging in the patient, and an improvement in the patient’s lung function, are seen in the same time frame. That is to say, the reduction in mucus plugging and the improvement in lung function take place at the same time. In such cases, the reduction in mucus plugging may be causative (at least in part) of the improvement in lung function.

In some embodiments, the improvement in lung function is an improvement (i.e. increase) in FEV1. In some cases, the increase in FEV1 is by at least 5 %, 10 %, 15 %, 20 %, 30 %, 40 %, 50 %, 60 %, 70 %, 80 %, 90 % or 100 %, relative to the FEV1 observed prior to the commencement of treatment. Such an increase may be in pre-bronchodilator (pre-BD) FEV1 or post-BD FEV1.

As noted above, prior to treatment, the patient may have a post-BD FEV1 of 80, 70, 60, 50, 40, 30 or 20 % or less of the predicted normal value. Following commencement of treatment with the anti-IL-33 antibody, the patient may have an improved post-BD FEV1 of at least 30, 40, 50, 60, 70 or 80 % of the predicted normal value. Thus in some instances, the patient may have a subnormal FEV1 prior to commencing treatment with the anti-IL-33 antibody, which improves to fall within the normal range following commencement of treatment with the anti-IL-33 antibody.

In some embodiments, the improvement in lung function is an improvement (i.e. an increase) in FVC. In some cases, the increase in FVC is by at least 5 %, 10 %, 15 %, 20 %, 30 %, 40 %, 50 %, 60 %, 70 %, 80 %, 90 % or 100 %, relative to the FVC observed prior to the commencement of treatment. Such an increase may be in pre-BD FVC or post-BD FVC, particularly in pre-BD FVC. As shown in the Examples below, a reduction in mucus plugging driven by anti-IL-33 therapy has been found to be correlated with an increase in pre-BD FVC.

In some embodiments, the improvement in lung function is an improvement (i.e. an increase) in the FEV1/FVC ratio. In some embodiments, the increase in FEV1/FVC ratio is of at least 5 %, 10 %, 15 %, 20 %, 30 %, 40 %, 50 %, 60 %, 70 %, 80 %, 90 % or 100 %, relative to the ratio prior to commencing anti-IL-33 treatment. In some embodiments, the increase in FEV1/FVC is an absolute increase of at least 0.1 , 0.2, 0.3, 0.4, 0.5, 0.6 or 0.7. In some embodiments, the increase in FEV1/FVC ratio is to > 0.5, 0.6 or 0.7. In some embodiments, the increase in FEV1/FVC ratio is to > 0.75, > 0.80 or > 0.85. Thus in some instances, the patient may have a subnormal FEV1/FVC ratio prior to commencing treatment with the anti-IL-33 antibody, indicative of an obstructive lung disease, which improves to fall within the healthy range following commencement of treatment with the anti-IL-33 antibody.

In some cases the improvement in lung function (e.g. FEV1 , FVC or FEV1/FVC ratio) is observed at week 4, 8, 12, 24, 28, 32, 36 or 52 following commencement of the anti-IL-33 treatment. Visualisation of Changes in Mucus Plugging

In some embodiments, the methods provided herein include visualisation of the change in mucus plugging resulting from the anti-IL-33 therapy. Such visualisation may be achieved by performing scans of the patient’s lungs before and after the commencement of anti-IL-33 therapy, and comparing the level of mucus plugging at the different time points.

Thus in some embodiments, the methods provided herein comprise performing a scan of the patient’s lungs to determine the level of mucus plugging prior to treatment with the anti-IL-33 antibody or fragment thereof.

In some embodiments, the methods provided herein comprise performing one or more scans of the patient’s lungs to determine the level of mucus plugging after at least one dose of the anti-IL-33 antibody or fragment thereof.

In some embodiments, the methods provided herein comprise:

(i) performing a baseline scan of the patient’s lungs to determine the level of mucus plugging prior to treatment with the anti-IL-33 antibody or fragment thereof; and

(ii) performing at least one follow-up scan of the patient’s lungs to determine the level of mucus plugging after at least one dose of the anti-IL-33 antibody or fragment thereof.

A “baseline” scan is defined herein as a scan performed to determine the level of mucus plugging in the patient prior to commencing treatment with the anti-IL-33 antibody or fragment thereof.

A follow-up scan may be performed a suitable interval after the first dose of the anti- IL-33 antibody therapy. A suitable interval after the first dose is sufficient time for the anti- IL-33 therapy to take effect and any resulting change in mucus plugging to be seen. Generally, a follow-up scan is not performed until at least 4 weeks after administration of the first dose of anti-IL-33 therapy. In some embodiments, a follow-up scan is not performed until multiple doses of the anti-IL-33 antibody have been administered. For example, a follow-up scan may be performed at least 8, 12, 16, 20, 24, 28, 36 or 52 weeks after administration of the first dose of the anti-IL-33 antibody.

Once a follow-up scan has been performed a comparison between the baseline scan and follow-up scan can be carried out to determine the reduction in the level of mucus plugging which has occurred as a result of the anti-IL-33 treatment.

Thus in some embodiments, the methods provided herein comprise:

(i) performing a baseline scan of the patient’s lungs to determine the level of mucus plugging prior to treatment with the anti-IL-33 antibody or fragment thereof;

(ii) performing at least one follow-up scan of the patient’s lungs to determine the level of mucus plugging after at least one dose of the anti-IL-33 antibody or fragment thereof; and

(iii) comparing a follow-up scan with the baseline scan to determine the reduction in the level of mucus plugging. In some embodiments, multiple follow-up scans are performed following the commencement of anti-IL-33 therapy, to continually review the effect of the treatment on mucus plugging. For example, follow-up scans may be performed at regular intervals following the commencement of treatment, e.g. every month, every 2 months, every 3 months, every 4 months, every 6 months or every year. Where multiple follow-up scans are performed, comparisons may be carried out between different follow-up scans. For example, each time a follow-up scan is carried out, a comparison may be made between the new follow-up scan and the previous follow-up scan, to determine any change in mucus plugging between scans. In this case, a comparison would be made between the first follow-up scan and the baseline scan. Thereafter, comparisons would be made between consecutive followup scans. In some cases, comparisons to the baseline may also continue to be made.

The lung scans may be carried out using any suitable technique in the art. Generally, the lung scans are carried out by CT scanning. In particular embodiments, the CT scans of the lungs are inspiratory CT scans, i.e. CT scans performed at full inspiration. The lung scan covers both lungs so that all mucus plugs in the airways of the lungs can be identified. In some embodiments, each scan is performed post administration of a bronchodilator. For example, each scan may be performed within 2 hours or within 1 hour of administration of a bronchodilator.

Identification of mucus plugs on a CT scan is routine for the skilled person, and is also described above. Identification of mucus plugs on a scan of the lungs, such as a CT scan, may also be automated, as described in e.g. Nardelli et al., American Journal of Respiratory and Critical Care Medicine 209: A5230, 2024.

In some embodiments, the level of mucus plugging in the patient’s lungs is quantified by a scoring system. In some such embodiments, the patient is assigned a score of 0-18, depending on the number of their lung segments which contain one or mucus plugs. That is to say, the patient’s mucus plugging score corresponds to the number of their lung segments which contain a mucus plug, e.g. a score of 0 indicates no mucus plugging, a score of 1 indicates that one of the patient’s lung segments contains one or more mucus plugs, etc. A maximum score of 18 indicates that all of the patient’s lung segments contain at least one mucus plug. Such a scoring system is demonstrated below. A similar scoring system is described in US 2019/0290225 (incorporated herein by reference).

Other scoring systems are also known in the art, e.g. based on total estimated mucus plug volume, and may be used to quantify the level of mucus plugging displayed by the patient. An automated mucus plugging quantification system may be used for scoring, e.g. as described in Tiddens et al., American Journal of Respiratory and Critical Care Medicine 209: A2778, 2024; or Huang et al., American Journal of Respiratory and Critical Care Medicine 205: A2177, 2022. In some embodiments, the determination of mucus plugging (e.g. calculation of a mucus plugging score) excludes assessment of the peripheral airways within 2 cm of the diaphragmatic pleura and costal pleura. As noted above, the narrowness of these airways can make it difficult to determine whether they are occluded by a mucus plug.

Thus the methods provided herein may comprise:

(i) performing a baseline scan of the patient’s lungs prior to treatment with the anti- IL-33 antibody or fragment thereof to determine the level of mucus plugging;

(ii) quantifying the level of mucus plugging at the baseline scan and assigning the patient a mucus plugging baseline score;

(iii) performing at least one follow-up scan of the patient’s lungs to determine the level of mucus plugging after at least one dose of the anti-IL-33 antibody or fragment thereof;

(iv) quantifying the level of mucus plugging at the follow-up scan and assigning the patient a mucus plugging follow-up score; and

(v) comparing a mucus plugging follow-up score with the mucus plugging baseline score to determine the reduction in the level of mucus plugging.

In such embodiments, the mucus plugging baseline score is the patient’s mucus plugging score at the baseline scan, i.e. the mucus plugging score prior to anti-IL-33 treatment. A mucus plugging follow-up score is the mucus plugging score at a follow-up scan. As set out above, multiple follow-up scans may be performed on the patient, and the patient may be assigned a mucus plugging follow-up score at each scan. By “quantifying the level of mucus plugging ... and assigning the patient a mucus plugging ... score” is meant that a mucus plugging score is calculated based on the level of mucus plugging observed in the scan. As set out above, where multiple follow-up scans are performed, the level of mucus plugging may be compared between different follow-up scans. In such embodiments, the mucus plugging follow-up score calculated at the first follow-up scan may be compared to the mucus plugging baseline score, and the mucus plugging follow-up score calculated at each subsequent scan then compared to the mucus plugging follow-up score calculated at the previous follow-up scan, so that the patient’s progress can be tracked. In such embodiments, a comparison to the mucus plugging baseline score may also be made.

Where the level of mucus plugging in the patient is quantified at each scan, and they are assigned mucus plugging scores, the reduction in the level of mucus plugging determined in step (v) corresponds to the reduction in the mucus plugging score relative to the baseline/previous scan.

As set out above, the patient treated according to the present methods has at least one mucus plug in their lungs. In some embodiments, the patient has a mucus plugging baseline score of at least 3, wherein the baseline score is calculated by assigning one point per lung segment containing a mucus plug. In some embodiments, the patient has a mucus plugging baseline score of at least 4, wherein the baseline score is calculated by assigning one point per lung segment containing a mucus plug. In the Examples below, such patients are defined as having a high baseline level of mucus plugging.

In some embodiments, the patient has a mucus plugging baseline score of at least 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, 16 or 17, wherein the baseline score is calculated by assigning one point per lung segment containing a mucus plug. In some embodiments using this scoring method, the patient has a maximum mucus plugging baseline score of 18.

As set out above, treatment of a patient according to the present methods may result in an improvement in the patient’s condition, i.e. a reduction in mucus plugging. When the level of mucus plugging in the patient is quantified and the patient is assigned a mucus plugging score at each scan, the improvement in the patient’s condition may correspond to an improvement in the patient’s mucus plugging score. In some embodiments, where the patient’s mucus plugging scores are calculated by assigning one point per lung segment containing a mucus plug, the treatment results in an improvement (i.e. reduction) in the patient’s mucus plugging score of at least 1 point.

In some embodiments, where the patient’s mucus plugging scores are calculated by assigning one point per lung segment containing a mucus plug, the treatment results in an improvement (i.e. reduction) in the patient’s mucus plugging score of at least 2 points.

In some embodiments, where the patient’s mucus plugging scores are calculated by assigning one point per lung segment containing a mucus plug, the treatment results in an improvement (i.e. reduction) in the patient’s mucus plugging score of at least 3, 4, 5, 6, 7, 8, 9 or 10 points.

As shown in the Examples, the higher a patient’s mucus plugging score, the greater the average reduction in mucus plugging seen. Thus in some embodiments, prior to treatment, the patient has a mucus plugging score of at least 4 (as calculated by assigning one point per lung segment containing a mucus plug), and the treatment provided herein causes a reduction in the patient’s mucus plugging score of at least 2.

Anti-IL-33 Antibodies

As set out above, the methods of treatment provided herein comprise administering an anti- IL-33 antibody or fragment thereof to the patient.

As defined herein, in line with standard terminology in the art, an antibody is an antigen-binding protein comprising two heavy chains and two light chains. The light chains are shorter (and thus lighter) than the heavy chains. The heavy chains comprise an N-terminal heavy chain variable domain, alternatively referred to as a variable region (VH), and the light chains comprise an N-terminal light chain variable domain (VL). The heavy and light chains each comprise constant domains (alternatively referred to as constant regions) C terminal to the respective variable domain.

Both the light and heavy chains of an antibody comprise three hypervariable complementarity-determining regions (CDRs) located within the variable domain. In a pair of a light chain and a heavy chain, the CDRs of the two chains form the antigen-binding site. The three CDRs of a heavy chain are known as VHCDR1 , VHCDR2 and VHCDR3, from N-terminus to C-terminus, and the three CDRs of a light chain are known as VLCDR1, VLCDR2 and VLCDR3, from N terminus to C terminus. Framework regions are located in between the CDRs and between the CDRs and ends of the variable domains. The framework regions largely adopt a p-sheet conformation and the CDRs form loops that connect, and in some cases form part of, the p-sheet structure. Thus, framework regions act to form a scaffold that provides for positioning the CDRs in correct orientation by inter-chain, non-covalent interactions. The antigen binding domain formed by the positioned CDRs defines a surface complementary to the epitope on the immunoreactive antigen. This complementary surface promotes the non-covalent binding of the antibody to its cognate epitope.

The constant domains of the light chain (CL) and the heavy chain (CH1 , CH2 or CH3) confer important biological properties such as secretion, transplacental mobility, Fc receptor binding, complement binding, and the like. By convention the numbering of the constant region domains increases as they become more distal from the antigen binding site or N-terminus of the antibody.

As used herein, the terms "antibody" and "immunoglobulin" are used interchangeably. The term "antibody" encompasses monoclonal antibodies, chimeric antibodies, humanized antibodies, human antibodies, bispecific antibodies, and any other immunoglobulin molecule so long as the antibodies exhibit the desired biological activity. An antibody can be of any of the five major classes of immunoglobulins: IgA, I g D, IgE, IgG, and IgM, or subclasses (isotypes) thereof (e.g. lgG1 , lgG2, lgG3, lgG-4, lgA1 , and lgA2), based on the identity of their heavy-chain constant domains referred to as alpha (a), delta (5), epsilon (5), gamma (y), and mu (p), respectively. The different classes of antibodies have different and well-known subunit structures and three-dimensional configurations.

Light chains are classified as either kappa or lambda (K or A). Each heavy chain class can be bound with either a kappa or lambda light chain. In general, the light and heavy chains are covalently bonded to each other, and the "tail" portions of the two heavy chains are bonded to each other by covalent disulfide linkages or non-covalent linkages when the immunoglobulins are generated either by hybridomas, B cells or genetically engineered host cells. In the heavy chain, the amino acid sequences run from an N-terminus at the forked ends of the Y configuration to the C-terminus at the bottom of each chain. Antigen-binding fragments of antibodies are fragments or synthetic constructs comprising one or more antigen-binding site of an antibody, but not the entire antibody. Generally an antigen-binding fragment of an antibody comprises the entire VL and VH domain sequences, but lacks at least part of the heavy and/or light chain constant domains. An antigen-binding fragment of an antibody can be monovalent or multi-valent (e.g. bivalent). An antigen-binding fragment of an antibody can be monospecific or multi-specific (e.g. bispecific).

The term "epitope" as used herein refers to an antigenic determinant that interacts with a specific antigen-binding site in the variable regions of an antibody molecule known as a paratope. Epitopes may be either conformational or linear. A conformational epitope is produced by spatially juxtaposed amino acids from different segments of the linear polypeptide chain. A linear epitope is one produced by adjacent amino acid residues in a polypeptide chain. In certain circumstances, an epitope may include post-translational modifications, such as moieties of saccharides, phosphoryl groups or sulfonyl groups on the antigen.

Generally, the anti-IL-33 antibody or fragment thereof used herein is a monoclonal antibody or fragment thereof. A “monoclonal antibody” (or antigen-binding fragment thereof) refers to a homogeneous antibody or antigen-binding fragment population. This is in contrast to polyclonal antibodies, which are heterogenous antibody populations that typically include antibodies directed against different antigenic determinants.

The anti-IL-33 antibody (or fragment thereof) binds IL-33 and inhibits IL-33 mediated activation of EGFR/RAGE. Generally, the anti-IL-33 antibody also inhibits IL-33 mediated activation of ST2/IL1 RAcP. That is to say, the anti-IL-33 antibody binds IL-33 and generally inhibits IL-33 mediated activation of both EGFR/RAGE and ST2/IL1 RAcP. Without being bound by theory, it is postulated that blockade of both IL-33 receptors may improve bronchiectasis treatment compared to blockade of just one or the other receptor.

Anti-IL-33 antibodies may be generated and identified using any suitable method known in the art. Inhibition of IL-33 mediated activation of EGFR/RAGE may be assessed using e.g. the scratch wound healing assay using A549 epithelial cells described in England et al., supra. Inhibition of IL-33 mediated activation of ST2/IL1 RAcP may be determined using the human umbilical vein endothelial cell (HUVEC) NF-KB/cytokine release assay also described in England et al., supra.

As set out above, the oxidised form of IL-33 (I L-33^OX) binds and activates the RAGE/EGFR complex, whereas the reduced form of IL-33 (IL-33^red) binds and activates the ST2/ ILI RAcP complex. The anti-IL-33 antibody for use herein may bind I L-33^OX and block its interaction with RAGE/EGFR. In some embodiments, the anti-IL-33 antibody binds I L-33^OX and IL-33^red, blocking the interaction of I L-33^OX with RAGE/EGFR and the interaction of I L-33^red with ST2/ ILI RAcP. Alternatively, the antibody may inhibit IL-33 interactions with RAGE/EGFR and ST2/ ILI RAcP by binding IL-33^red and blocking both the binding of IL-33^red to ST2/ ILI RAcP, and the oxidation of I L-33^red (thereby inhibiting activation of RAGE/EGFR by IL-33).

Thus in some embodiments, the anti-IL-33 antibody binds IL-33^red; in some embodiments the anti-IL-33 antibody binds IL-33^OX; and in some embodiments the anti-IL-33 antibody binds both IL-33^red and I L-33^OX. Where the antibody binds I L-33^red and IL-33^OX, the antibody may bind both the reduced and oxidised forms of IL-33 with approximately the same affinity, or it may bind one form of IL-33 with higher affinity than the other. I.e. the antibody may bind I L-33^red with higher affinity than I L-33^OX, or it may bind I L-33^OX with higher affinity than IL-33^red.

In some embodiments, the antibody binds I L-33^OX with an affinity (i.e. KD) of at least IO’⁷ M, 5 x 10’⁸ M, 10’⁸ M, 5 x 10’⁹ M, 10’⁹ M, 5 x 1O’¹⁰ M or 1O’¹⁰ M. By “a K_D of at least 10'⁷ M” is meant a KD of 10'⁷ M or less. In some embodiments, the antibody binds IL-33^red with an affinity (i.e. K_D) of at least 1 IO’¹⁰ M, 5 x 10’¹¹ M, 10’¹¹ M, 5 x 10 some embodiments, the antibody binds I L-33^red with an affinity at least equivalent to the affinity of IL-33^red for ST2 (i.e. 90 fM, see England et al., supra). Thus in some embodiments, the antibody binds I L-33^red with an affinity of at least 90 fM, 80 fM, 70 fM, 60 fM, 50 fM, 40 fM or 30 fM.

In some embodiments, the antibody binds I L-33^red with an affinity at least equivalent to the affinity of I L-33^red for ST2, and binds IL-33^OX with an affinity of at least 100 nM, 90 nM, 80 nM, 70 nM, 60 nM or 50 nM.

The anti-IL-33 antibody generally binds IL-33 specifically, in particular human IL-33. As defined herein, an antibody which binds specifically to human IL-33 is an antibody which binds to human IL-33 with a greater affinity than that with which it binds to other molecules, or at least most other molecules. An antibody which binds specifically to human IL-33 may display cross-reactivity with IL-33 from other species, but generally does not bind other human proteins, particularly other human proteins related to IL-33, or binds them with a much lower affinity than with which it binds IL-33. For example, the antibody generally does not bind other members of the IL-1 family, such as I L-1a and IL-1 p, or binds them only much more weakly than it binds IL-33. For instance, the antibody may bind other proteins, such as other IL-1 family members, at least 3, 4, 5, 6, 7 or 8 orders of magnitude more weakly than it binds to IL-33. The anti-IL-33 antibody may specifically bind human I L-33^red, human IL-33^OX or both human I L-33^red and I L-33^OX.

The antibody used herein may comprise: (a) a heavy chain variable region comprising a VHCDR1 comprising the sequence of SEQ ID NO: 1, a VHCDR2 comprising the sequence of SEQ ID NO: 2, and a VHCDR3 comprising the sequence of SEQ ID NO: 3; and

(b) a light chain variable region comprising a VLCDR1 comprising the sequence of SEQ ID NO: 4, a VLCDR2 comprising the sequence of SEQ ID NO: 5, and a VLCDR3 comprising the sequence of SEQ ID NO: 6.

The antibody or antigen-binding fragment thereof used herein may be a human antibody or antigen-binding fragment thereof. In particular, the human antibody or fragment thereof may comprise the CDRs of SEQ ID NOs: 1-6, as detailed above. As used herein, the term “human antibody” includes antibodies having the amino acid sequence of a human immunoglobulin and includes antibodies isolated from human immunoglobulin libraries or from animals transgenic for one or more human immunoglobulins and that do not express endogenous immunoglobulins.

The antibody or fragment thereof used herein may comprise a heavy chain variable region comprising the sequence set forth in SEQ ID NO: 7, or an amino acid sequence with at least 80, 85, 90 or 95 % sequence identity thereto. When a heavy chain variable region is used which is a variant of SEQ ID NO: 7 (i.e. it comprises an amino acid sequence with at least 80 %, but less than 100 %, identity to SEQ ID NO: 7), the heavy chain CDR sequences are as set out in SEQ ID NOs: 1-3, i.e. any sequence variation is located in the framework sequences.

The antibody or fragment thereof used herein may comprise a light chain variable region comprising the sequence set forth in SEQ ID NO: 8, or an amino acid sequence with at least 80, 85, 90 or 95 % sequence identity thereto. When a light chain variable region is used which is a variant of SEQ ID NO: 8 (i.e. it comprises an amino acid sequence with at least 80 %, but less than 100 %, identity to SEQ ID NO: 8), the light chain CDR sequences are as set out in SEQ ID NOs: 4-6, i.e. any sequence variation is located in the framework sequences.

The antibody or fragment thereof used herein may comprise a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 7, or an amino acid sequence with at least 80, 85, 90 or 95 % sequence identity thereto; and a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 8, or an amino acid sequence with at least 80, 85, 90 or 95 % sequence identity thereto.

In some embodiments, the antibody or fragment thereof used herein comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 7, and a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 8.

As used herein, the term “sequence identity” or “identity” denotes a property of sequences that measures their similarity or relationship. The term “sequence identity” or “identity” as used herein means the percentage of pair-wise identical residues - following (homologous) alignment of a sequence of a protein or polypeptide of interest with a reference sequence - with respect to the number of residues in the longer of these two sequences. Sequence identity is measured by dividing the number of identical amino acid residues by the total number of residues and multiplying the product by 100.

A skilled artisan will recognize available computer programs, for example BLAST (Altschul et al., Nucleic Acids Res, 1997), BLAST2 (Altschul et al., J Mol Biol, 1990), FASTA (which uses the method of Pearson and Lipman (1988)), the TBLASTN program, of Altschul et al. (1990) supra, GAP (Wisconsin GCG package, Accelerys Inc, San Diego USA) and Smith-Waterman (Smith and Waterman, J Mol Biol, 1981), for determining sequence identity using standard parameters. The percentage of sequence identity can, for example, be determined herein using the program BLASTP, version 2.2.5, November 16, 2002 (Altschul et al., Nucleic Acids Res, 1997). In this instance, the percentage of homology is based on the alignment of the entire protein or polypeptide sequences (matrix: BLOSUM 62; gap costs: 11.1 ; cut off value set to 10'³). It is calculated as the percentage of numbers of “positives” (homologous amino acids) indicated as result in the BLASTP program output divided by the total number of amino acids selected by the program for the alignment. Sequence identity is commonly defined with reference to the algorithm GAP (Wisconsin GCG package, Accelerys Inc, San Diego USA). GAP uses the Needleman and Wunsch algorithm to align two complete sequences, maximising the number of matches and minimising the number of gaps, which are spaces in an alignment that are the result of additions or deletions of amino acids. Generally, default parameters are used, with a gap creation penalty equalling 12 and a gap extension penalty equalling 4.

In some embodiments, the patient is administered an anti-IL-33 antibody (that is to say, a full-length anti-IL-33 antibody). The full-length antibody may be of any isotype or subclass thereof. In particular, the antibody may be an IgG, e.g. lgG1 , lgG2, lgG3 or lgG4 antibody. Most particularly, the antibody may be an IgG 1 antibody. In particular, the antibody may comprise a human lgG1 constant region.

In particular embodiments, the antibody used herein is tozorakimab, as disclosed in WO 2016/156440, which is incorporated herein by reference. Tozorakimab is also referred to in the art as MEDI3506 and 33_640087_7B. The heavy chain of tozorakimab has the amino acid sequence set forth in SEQ ID NO: 9, and the light chain of tozorakimab has the amino acid sequence set forth in SEQ ID NO: 10.

Tozorakimab is a fully human I gG 1 monoclonal antibody that is being developed for the treatment of inter alia chronic obstructive pulmonary disease (COPD). As set out above, tozorakimab binds human I L-33^red and prevents binding of IL 33^red to the ST2 receptor, and prevents oxidation of I L-33^red. Tozorakimab binds human IL-33^red with an exceptionally high affinity of approximately 30 fM, and fully neutralises full-length and all mature forms of endogenous IL-33^red (Scott et a/., ERS International Congress 2022, Barcelona (ES), Abstract OA2254).

In other embodiments, an anti-IL-33 antibody is used which is not tozorakimab, but which has similar, or the same, pharmacokinetic (pK) characteristics as tozorakimab in humans.

For example, the anti-IL-33 antibody may have a similar, or the same, half-life in humans as tozorakimab. The anti-IL-33 antibody having a similar, or the same, half-life in humans as tozorakimab, when administered at a dose of 30 mg Q2W, may have a half-life of about 10 to about 20 days, about 12 to about 15 days, or of about 12.7 days. The anti-IL-33 antibody having a similar, or the same, half-life in humans as tozorakimab, when administered at a dose of 100 mg Q2W, may have a half-life of about 10 to about 20 days, about 12 to about 15 days, or of about 13.2 days. The anti-IL-33 antibody having a similar, or the same, half-life in humans as tozorakimab, when administered at a dose of 300 mg Q2W, may have a half-life of about 10 to about 20 days, about 12 to about 15 days, or of about 14.8 days.

In some embodiments, the IL-33 antibody may competitively inhibit binding of IL-33 to tozorakimab. An antibody is said to competitively inhibit binding of a reference antibody to a given epitope if it specifically binds to (or close to) that epitope to the extent that it blocks, to some degree, binding of the reference antibody to its epitope. Competitive inhibition may be determined by any method known in the art, for example, solid phase assays such as competition ELISA assays, Dissociation-Enhanced Lanthanide Fluorescent Immunoassays (DELFIA®, Perkin Elmer), and radioligand binding assays. For example, the skilled person could determine whether an antibody competes for binding to IL-33 by using an in vitro competitive binding assay, such as the HTRF assay described in WO 2016/156440, paragraphs 881-886, which is incorporated herein by reference. For example, the skilled person could label tozorakimab with a donor fluorophore and mix multiple concentrations with fixed concentration samples of acceptor fluorophore labelled-l L-33^red. Subsequently, the fluorescence resonance energy transfer between the donor and acceptor fluorophore within each sample can be measured to ascertain binding characteristics. To elucidate competitive binding antibody molecules, the skilled person could first mix various concentrations of a test binding molecule with a fixed concentration of the labelled tozorakimab antibody. A reduction in the FRET signal when the mixture is incubated with labelled IL-33 in comparison with a labelled antibody-only positive control would indicate competitive binding to IL-33. An antibody may be said to competitively inhibit binding of tozorakimab to IL-33 if it reduces tozorakimab binding to IL-33 by at least 90 %, at least 80 %, at least 70 %, at least 60 %, or at least 50 %, when both it and tozorakimab are used at the same concentration.

Alternatively, the patient may be administered an antigen-binding fragment of an anti- IL-33 antibody. In some embodiments, the patient is administered an antigen-binding fragment of tozorakimab. Antigen-binding fragments of antibodies are discussed in Rodrigo et al., Antibodies, Vol. 4(3), p. 259-277, 2015. Antibody fragments which may be used herein include, for example, Fab, F(ab')2, Fab' and Fv fragments. Fab fragments are discussed in Nelson, mAbs 2(1): 77-83, 2010. A Fab fragment consists of the antigen-binding domain of an antibody, i.e. an individual antibody may be seen to contain two Fab fragments, each consisting of a light chain and its conjoined N-terminal section of the heavy chain. Thus a Fab fragment contains an entire light chain and the VH and CH1 domains of the heavy chain to which it is bound. Fab fragments may be obtained by digesting an antibody with papain.

F(ab')2 fragments consist of the two Fab fragments of an antibody, plus the hinge regions of the heavy domains, including the disulphide bonds linking the two heavy chains together. In other words, a F(ab')2 fragment can be seen as two covalently joined Fab fragments. F(ab')2 fragments may be obtained by digesting an antibody with pepsin.

Reduction of F(ab')2 fragments yields two Fab' fragments, which can be seen as Fab fragments containing an additional sulfhydryl group which can be useful for conjugation of the fragment to other molecules.

Fv fragments consist of just the variable domains of the light and heavy chains. These are not covalently linked and are held together only weakly by non-covalent interactions. Fv fragments can be modified to produce a synthetic construct known as a single chain Fv (scFv) molecule. Such a modification is typically performed recombinantly, by engineering the antibody gene to produce a fusion protein in which a single polypeptide comprises both the VH and VL domains. scFv fragments generally include a peptide linker covalently joining the VH and VL regions, which contributes to the stability of the molecule. The linker may comprise from 1 to 20 amino acids, such as for example 1 , 2, 3 or 4 amino acids, 5, 10 or 15 amino acids, or other intermediate numbers in the range 1 to 20 as convenient. The peptide linker may be formed from any generally convenient amino acid residues, such as glycine and/or serine. One example of a suitable linker is Gly4Ser. Multimers of such linkers may be used, such as for example a dimer, a trimer, a tetramer or a pentamer, e.g. (Gly4Ser)2, (Gly4Ser)3, (Gly4Ser)4 or (Gly4Ser)s. However, it is not essential that a linker be present, and the VL domain may be linked to the VH domain by a peptide bond. An scFv is herein defined as an antibody fragment, or antigen-binding fragment of an antibody. Thus the antibody fragment used herein may be a Fab, F(ab')2, Fab', Fv or scFv. In some embodiments, the antibody fragment used herein is multivalent, e.g. a diabody, triabody or tetrabody. Diabodies, triabodies and tetrabodies are described in Cuesta et al., Trends in Biotechnology 28(7): 355-362, 2010.

Antibody Administration

The antibody may be administered within a pharmaceutical composition. The pharmaceutical compositions may be formulated with suitable carriers, excipients, and other agents that provide suitable transfer, delivery, tolerance, and the like. A multitude of formulations can be found in the formulary known to all pharmaceutical chemists: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. Thus, the pharmaceutical compositions may comprise, in addition to the active ingredient (i.e. the anti-IL-33 antibody), a pharmaceutically acceptable excipient, carrier, buffer, stabiliser or other material well known to those skilled in the art. Such materials should be non-toxic and should not interfere with the efficacy of the active ingredient. The precise nature of the carrier or other material will depend on the route of administration, which may be by injection.

The pharmaceutical composition may be an aqueous solution which is pyrogen-free and has suitable pH, isotonicity and stability. The pharmaceutical composition may be a liquid formulation or a lyophilized formulation which is reconstituted before use. As excipients for a lyophilized formulation, for example, sugar alcohols, or saccharides (e.g. mannitol or glucose) may be used. In the case of a liquid formulation, the pharmaceutical composition is usually provided in the form of containers with defined volume, including sealed and sterilized plastic or glass vials, ampoules and syringes, as well as in the form of large volume containers like bottles. Generally, in the methods described herein, the pharmaceutical composition is a liquid formulation. Commonly, such a liquid pharmaceutical composition is provided in a vial. When the anti-IL-33 antibody is provided in a liquid composition, the composition may be buffered to a pH of 5.2 to 5.7, most suitably about 5.5 (± 0.1).

It will be appreciated that references to a "pharmaceutically acceptable excipient" includes references to any excipient conventionally used in pharmaceutical compositions. Such excipients may typically include one or more surfactant, inorganic or organic salt, stabilizer, diluent, solubilizer, reducing agent, antioxidant, chelating agent, preservative and the like.

In some embodiments, a surfactant is present within the pharmaceutical composition in an amount of from 0.001 % to 0.1 % (w/w). For example, the surfactant may be polysorbate-80 (PS-80).

The anti-IL-33 antibody (particularly tozorakimab) may be provided in a pharmaceutical composition comprising L-histidine and/or L-histidine hydrochloride, L-arginine hydrochloride and polysorbate 80. The composition may in particular comprise 20 mM ± 10 % L-histidine/L-histidine hydrochloride, e.g. 20 mM ± 2.5 %, 5 % or 7.5 % L-histidine/L-histidine hydrochloride. That is to say L-histidine/L-histidine hydrochloride may be present in the composition at a concentration from 18-22, 18.5-21.5, 19-21 or 19.5- 20.5 mM, in particular at a concentration of 20 mM.

The composition may in particular comprise 220 mM ± 10 % L-arginine hydrochloride, e.g. 220 mM ± 2.5 %, 5 % or 7.5 % L-arginine hydrochloride. For instance, L-arginine hydrochloride may be present in the composition at a concentration from 200-240, 205-235, 210-230 or 215-225 mM, in particular at a concentration of 220 mM.

The composition may in particular comprise 0.03 % w/v ± 10 % polysorbate 80, e.g. 0.03 % w/v ± 2.5 %, 5 % or 7.5 % polysorbate 80. For instance, polysorbate 80 may be present in the composition at a concentration from 0.027-0.033, 0.028-0.032 or 0.029-0.031 % w/v, in particular at a concentration of 0.03 % w/v.

The composition may have a pH from 5.2-5.7, 5.3-5.6 or 5.4-5.5, in particular 5.5.

In some embodiments, the pharmaceutical composition comprises 20 mM L-histidine/L-histidine hydrochloride, 220 mM L-arginine hydrochloride and 0.03 % w/v polysorbate 80, and has a pH of 5.5.

The anti-IL-33 antibody may be administered to the subject by any suitable route known in the art. In particular, the anti-IL-33 antibody may be administered to the patient subcutaneously.

The anti-IL-33 antibody is administered in a therapeutically effective amount. As used herein, an “effective amount” or “therapeutically effective amount” of the anti-IL-33 antibody refers to an amount effective, at dosages and for periods of time necessary, to achieve the desired therapeutic result.

Any suitable antibody dosage may be used. Generally, the antibody is administered as a flat dose (i.e. a body weight-independent dose). In some embodiments, the anti-IL-33 antibody (particularly tozorakimab). is administered in a dose of about 200 to about 800 mg, about 250 to about 700 mg or about 300 mg to about 600 mg. In some embodiments, the anti-IL-33 antibody is administered in a dose of about 250 to about 350 mg, about 260 to about 340 mg, about 270 to about 330 mg, about 280 to about 320 mg, about 290 to about 310 mg, about 295 to about 305 mg or about 300 mg. In some embodiments, the anti-IL-33 antibody is administered in a dose of about 550 to about 650 mg, about 560 to about 640 mg, about 570 to about 630 mg, about 580 to about 620 mg, about 590 to about 610 mg, about 595 to about 605 mg or about 600 mg.

In particular embodiments, the dose is 300 mg. In some embodiments, the anti-IL-33 antibody is formulated for subcutaneous injection at 150 mg/ml, such that a 300 mg dose is administered as a 2 ml treatment. In some embodiments, a 300 mg dose of the anti-IL-33 antibody is administered as two concurrent 150 mg doses. As used herein, the term “concurrent doses” refers to doses which are administered simultaneously, or sequentially with no or only a minimal time period (e.g. less than 1 hour, less than 30 minutes, less than 15 minutes, less than 5 minutes) separating them.

The size of the dose of the anti-IL-33 antibody may be expressed in terms of the plasma drug concentration provided by the dose, as the amount of active compound administered so as to provide a plasma drug concentration of a certain level. By varying the amount, bioavailability, or timing/frequency of the antibody administered, the skilled person can control the plasma concentration in the subject. As plasma concentrations vary across time with drug uptake and clearance, they may be expressed in various standardised ways - for example as a maximum, minimum (trough) or across time.

In some embodiments, the dose is selected so as to provide a Cmax.ss (the observed maximum concentration at steady state) of between about 20 and about 50 pg/ml, between about 25 and about 45 pg/ml, between about 30 and about 40 pg/ml, between about 35 and about 40 pg/ml, or about 37 pg/ml. In some embodiments, the dose is selected so as to provide a Cmax.ss of between about 10 and about 35 pg/ml, between about 15 and about 30 pg/ml, between about 15 and about 30 pg/ml, between about 15 and about 25 pg/ml, about 15 to about 20 pg/ml, or about 18.6 pg/ml. In some instances, the Cmax.ss is that observed during the dosing period. In this context, the “dosing period” refers to the time between two consecutive doses.

In some embodiments, the anti-IL-33 antibody is administered at a dose selected so as to provide an area under the plasma concentration-time curve throughout a dosing period (AUC).

In some embodiments, the dose is selected so as to provide an AUC of between about 400 and about 800 pg ■ day/ml, between about 500 and about 750 pg ■ day/ml, between about 600 and about 700 pg ■ day/ml, between about 600 and about 650 pg ■ day/ml, between about 600 and about 620 pg ■ day/ml, between about 610 and about 620 pg ■ day/ml, or about 616 pg ■ day/ml over the dosing period. In some embodiments, the dose is selected so as to provide an AUC of between about 200 and about 515 pg ■ day/ml, between about 250 and about 500 pg ■ day/ml, between about 300 and about 450 pg ■ day/ml, between about 300 and about 350 pg ■ day/ml, or about 323 pg ■ day/ml over the dosing period. In some embodiments, the dose is selected so as to provide an AUC of between about 100 and about 300 pg ■ day/ml, between about 100 and about 250 pg ■ day/ml, between about 100 and about 200 pg ■ day/ml, between about 150 and about 200 pg ■ day/ml, or about 161.5 pg ■ day/ml over the dosing period.

Administration of the anti-IL-33 antibody is performed as multiple doses separated by a dosing interval. In some embodiments, the dosing interval is 1 to 4 weeks, e.g. 1 week (7 days), 2 weeks (14 days), 3 weeks (21 days) or 4 weeks (28 days). In particular embodiments, the anti-IL-33 antibody is administered to the patient at a dose of 200 mg to 800 mg every 1 to 4 weeks, e.g. 300 mg to 600 mg every 1 to 4 weeks, 250 to 350 mg every 1 to 4 weeks or 550-650 mg every 1 to 4 weeks. In particular embodiments, tozorakimab is administered to the patient at a dose of 200 mg to 800 mg every 1 to 4 weeks, e.g. 300 to 600 mg every 1 to 4 weeks, 250 to 350 mg every 1 to 4 weeks or 550-650 mg every 1 to 4 weeks.

In particular embodiments, the anti-IL-33 antibody (in particular tozorakimab) is administered to the patient at a dose of 300 to 600 mg every 2 weeks or every 4 weeks, at a dose of 250 to 350 mg every 2 weeks or every 4 weeks, or at a dose of 550 to 650 mg every 4 weeks.

In particular embodiments, the anti-IL-33 antibody (in particular tozorakimab) is administered to the patient at a dose of 300 mg every 2 weeks or every 4 weeks, or at a dose of 600 mg every 4 weeks.

In particular embodiments, the anti-IL-33 antibody (in particular tozorakimab) is administered to the patient at a dose of 300 mg every 2 weeks.

When the dosing interval is expressed as a number of weeks, a margin of error is permissible such that a week may be expressed as 7 days ± 1 day. Where the dosing interval is multiple weeks, the margins of error in each week may be combined. For example, the dosing interval may be 2 weeks ± 2 days, or 4 weeks ± 4 days.

According to the methods provided herein, the anti-IL-33 antibody is administered over a course of therapy. The course of therapy is a period of time commencing at the administration of the first dose and running until the administration of the final dose of the anti-IL-33 antibody.

In some embodiments, the course of therapy lasts at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks. In some embodiments, the course of therapy lasts at least 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 15, 18, 21 or 24 months. In some embodiments, the course of therapy lasts at least 1, 2, 3, 4 or 5 years. In some embodiments, the course of therapy is lifelong, i.e. it is not stopped until the patient dies.

In particular embodiments, the patient is administered tozorakimab for a course of therapy lasting at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 15, 18, 21 or 24 months; or 1 , 2, 3, 4 or 5 years.

In some embodiments, the patient is administered tozorakimab every 1-4 weeks over a course of therapy lasting at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 15, 18, 21 or 24 months; or 1 , 2, 3, 4 or 5 years. In some embodiments, the patient is administered 200-800 mg tozorakimab every 1- 4 weeks over a course of therapy lasting at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 15, 18, 21 or 24 months; or 1 , 2, 3, 4 or 5 years.

In some embodiments, the patient is administered 300-600 mg, 250-350 mg or 550- 650 mg tozorakimab every 1-4 weeks over a course of therapy lasting at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 18, 21 or 24 months; or 1 , 2, 3, 4 or 5 years.

In particular embodiments, the patient is administered 300-600 mg tozorakimab every 2 or 4 weeks over a course of therapy lasting at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 18, 21 or 24 months; or 1 , 2, 3, 4 or 5 years.

In particular embodiments, the patient is administered 250-350 mg tozorakimab every 2 or 4 weeks over a course of therapy lasting at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 18, 21 or 24 months; or 1 , 2, 3, 4 or 5 years.

In particular embodiments, the patient is administered 550-650 mg tozorakimab every 4 weeks over a course of therapy lasting at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 15, 18, 21 or 24 months; or 1, 2, 3, 4 or 5 years.

In particular embodiments, the patient is administered 300 mg tozorakimab every 2 or 4 weeks, or 600 mg tozorakimab every 4 weeks, over a course of therapy lasting at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 18, 21 or 24 months; or 1 , 2, 3, 4 or 5 years.

In particular embodiments, the patient is administered 300 mg tozorakimab every 2 weeks over a course of therapy lasting at least 12 weeks, 16 weeks, 20 weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks, 40 weeks, 44 weeks, 48 weeks or 52 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 15, 18, 21 or 24 months; or 1 , 2, 3, 4 or 5 years.

It will be understood that the features set out in the detailed description above, though commonly described in the context of the methods provided herein, are applicable to all aspects provided here. I.e. the features described above are applicable to the various methods provided herein, the anti-IL-33 antibody or antigen-binding fragment thereof for use in methods of treatment provided herein, the uses of an anti-IL-33 antibody or antigenbinding fragment thereof in the manufacture of a medicament provided herein, the uses of an anti-IL-33 antibody or antigen-binding fragment thereof provided herein, and the pharmaceutical composition comprising an anti-IL-33 antibody or antigen-binding fragment thereof for use in methods of treatment provided herein, along with any and all other related aspects which may be considered to be provided herein. The present methods and related aspects may be better understood in view of the non-limiting examples below.

EXAMPLES

Example 1: A Phase II, Randomized, Double-blind, Placebo-controlled Study to Assess the Efficacy Safety and Tolerability of MEDI3506 in Participants with Moderate to Severe Chronic Obstructive Pulmonary Disease and Chronic Bronchitis (FRONTIER 4)

The present example sets out the protocol for the FRONTIER 4 trial of tozorakimab in patients with COPD. This trial was performed in order to evaluate the efficacy, safety, PK, and immunogenicity of MEDI3506 (tozorakimab) in adult subjects with moderate or severe COPD receiving Standard of Care (dual or triple therapy) as maintenance therapy. Participants also have a history of > 1 moderate or severe acute exacerbation in the previous 12 months while on stable background treatment, and moderate to severe chronic bronchitis, with active sputum and cough symptoms. Within the trial, a sub-group of patients were analysed to assess the effect of tozorakimab on mucus plugging.

Participants must have been on stable doses of dual therapy (ICS + LABA or LABA + LAMA) or triple therapy (ICS + LABA + LAMA) for > 3 months prior to enrolment and remained so during the study. There should have been no change in maintenance COPD treatment after a previous exacerbation prior to entering into the study.

Participants were randomised into treatment groups which received either 600 mg MEDI3506 SC (20 mM L-histidine/L-histidine-hydrochloride, 220 mM L-arginine- hydrochloride, 0.03% (w/v) polysorbate 80, pH 5.5), or volume-matched placebo SC (referred to collectively as “investigational products”) in a 1 :1 ratio overall every 4 weeks (Q4W) for a total of 7 doses with the final dose at Week 24. SC = subcutaneously.

Participants were enrolled in the study for at least a 4-week screening/run-in period, a 24-week intervention period (or “treatment window”) during which they received 7 doses SC Q4W, a 4 week additional period, and an 8-week follow-up period.

Inclusion Criteria

Participants were required to meet the following criteria:

1 . Participants must be 40 to 80 years of age inclusive.

2. Participants must be current or ex-smokers with a tobacco history of > 10 pack- years. - Participants must have a documented history of COPD for at least 1 year. Participants must have a post-BD FEV1/FVC < 0.70 and a post-BD FEV1 > 20% and < 80% predicted normal value at screening. Centralized spirometry was used for this criteria assessment. Participants must have a physician confirmed participant history of chronic bronchitis as defined as presence of cough and sputum on most days for > 3 mos/yr in at least the 2 year period immediately prior to SV1 (study visit 1) (screening). Participants must have an average BCSS score of > 2 in cough and > 2 in sputum domains assessed over the 14 days preceding SV3. Participants must have a documented stable regimen of dual therapy or triple therapy for > 3 months prior to enrolment; there should have been no change in treatment after the previous exacerbation prior to entering into the study. Dual therapy consists of ICS + LABA or LABA + LAMA, and triple therapy consists of ICS + LABA + LAMA. Both dual and triple therapy may be in the form of separate inhalers of fixed dose combination inhalers but may not be in nebulized form. Participants must have a documented history of > 1 moderate or severe AECOPD (acute exacerbation of chronic obstructive pulmonary disease) requiring systemic corticosteroids and/or antibiotics for at least 3 days duration (or 1 injection of depot formulation), or hospitalization for reason of AECOPD in the previous 24 months prior to screening. Participants must be clinically stable and free from an exacerbation of COPD for 1 month prior to SV1 (screening) and prior to Day 1. Participants must be at least 70 % compliant with the eDiary and home spirometry during the 14 days preceding SV3 based on the eDiary. Participants must be able to read, write, and use electronic devices. Participants must have a body mass index within the range 18 to 40 kg/m² (inclusive). Female participants of childbearing potential, must have negative pregnancy tests at screening SV1 (serum pregnancy test), and then subsequently at SV2 (urine pregnancy test, only if a CT scan is performed) and pre-dose of study intervention at SV3 (Day 1 ; urine pregnancy test). Female participants of childbearing potential who are sexually active with a male partner must agree to use a highly effective method of contraception from screening until the end of the follow-up period at SV14 of the study. In countries where spermicide is available, it is strongly recommended for the male partner of a female participant of childbearing potential to also use male condom plus spermicide throughout this period. In countries where spermicide is not available, it is strongly recommended for the male partner of a female participant of childbearing potential to also use male condom throughout this period. All female participants should refrain from egg cell donation and breastfeeding throughout the study.

16. In countries where spermicide is available, male participants who are sexually active with a female partner of childbearing potential must agree to use a male condom with spermicide and another highly effective method of contraception during the intervention and follow-up periods from Day 1 through to SV14 of the study. In countries where spermicide is not available, male participants who are sexually active with a female partner of childbearing potential must agree to use a male condom and another highly effective method of contraception during the intervention and follow-up periods from Day 1 through to SV14 of the study. Male participants should also refrain from biologically fathering a child or donating sperm during the same period.

17. Participants must be capable of giving signed informed consent.

18. For enrolment in a sub-study, participants must provide signed and dated written informed consent.

Exclusion Criteria

Participants were excluded from the study if any of the following criteria applied:

1. Participants with a positive diagnostic nucleic acid test for SARS-CoV-2 at SV1 or SV2. Subjects with mild or asymptomatic disease could be rescreened.

2. Participants with a significant COVID-19 illness within 6 months of enrolment defined as:

(a) a diagnosis of COVID-19 pneumonia based on radiological assessment;

(b) a diagnosis of COVID-19 with significant new findings from pulmonary imaging tests;

(c) a diagnosis of COVID-19 requiring hospitalisation and/or oxygen supplementation therapy.

3. Any evidence of any active medical or psychiatric condition or other reason (at screening [SV1 and SV2] and SV3 [pre-dose]) which makes it undesirable for the participant to participate in the study. This included but was not limited to:

(a) diabetes mellitus, except for participants with type 2 diabetes mellitus who are well controlled;

(b) history of heart failure; (c) clinically significant or unstable ischemic heart disease, arrhythmia including atrial fibrillation (except first degree heart block), or cardiomyopathy, including acute coronary syndrome within the last 6 months, or any history of myocardial infarction;

(d) clinically significant aortic stenosis;

(e) systemic hypertension, except if well controlled and stable for at least 3 months;

(f) pulmonary arterial hypertension;

(g) history of an underlying condition that predisposes the participant to infections (e.g. history of splenectomy, known primary or secondary immune deficiency syndromes);

(h) history of ulcerative colitis, Crohn’s disease, or microscopic colitis diagnosed by either a gastroenterologist or by histopathology.

4. -

5. Current diagnosis of asthma or past diagnosis of asthma which persisted beyond the age of 25 years. A misdiagnosis of asthma is not exclusionary if any of the following are met:

(a) a diagnosis of asthma that was, within 2 years of original diagnosis, determined to be a misdiagnosis by the then-treating physician;

(b) a brief episode of asthma-like symptoms without longer-term asthma treatment confirmed to be a misdiagnosis;

(c) a diagnosis of asthma made when the subject was aged > 40 years, confirmed to be a misdiagnosis.

6. Clinically important pulmonary disease other than COPD (e.g. active lung infection, clinically significant bronchiectasis, pulmonary fibrosis, cystic fibrosis, hypoventilation syndrome associated with obesity, lung cancer, alpha-1 anti-trypsin deficiency and primary ciliary dyskinesia) or another diagnosed pulmonary or systemic disease that is associated with elevated peripheral eosinophil counts (e.g. allergic bronchopulmonary aspergillosis/mycosis, Churg-Strauss syndrome, hypereosinophilic syndrome), radiological findings, and/or laboratory findings suggestive of a respiratory disease other than COPD that is contributing to the participant's respiratory symptoms.

7. Increased pre-BD FEV1 at randomization visit (SV3) compared to Screening SV1 of > 400 mL or > 25% of SV1 FEV1 .

8. Known history of allergy or reaction to any component of the study intervention formulation, including hereditary fructose intolerance.

9. Any other clinically relevant abnormal findings on physical examination, laboratory testing including hematology, coagulation, serum chemistry, or urinalysis; or chest CT scan at screening or randomization, which may compromise the safety of the participant in the study or interfere with evaluation of the study intervention or reduce the participant’s ability to participate in the study. Abnormal findings include, but are not limited to:

(a) ALT or AST > 2 x ULN;

(b) TBL > 2 x ULN (unless due to Gilbert’s disease);

(c) evidence of chronic liver disease;

(d) abnormal vital signs, after 10 minutes of being in a comfortable supine position (confirmed by 1 controlled measurement), defined as any of the following:

(i) systolic BP < 80 mmHg or > 150 mmHg;

(ii) diastolic BP < 50 mmHg or > 95 mmHg;

(iii) pulse < 45 or > 100 beats per minute.

(e) -

(f) any clinically significant rhythm, conduction, or morphology abnormalities in the 12 lead ECG including but not limited to corrected QT interval (Fridericia) (Vandenberk et al 2016) > 450 ms;

(g) chest CT scan findings requiring further investigation or repeat CT surveillance before SV14.

10. -

11. A family history of heart failure defined as either of the following: > 2 first degree relatives with clinically significant heart failure, or > 1 first degree relative with heart failure known to be heritable (e.g. hypertrophic cardiomyopathy), unless inheritance is excluded by genetic testing.

12. A LVEF < 45% measured by echocardiogram during screening, between the time of signing informed consent and prior to randomization.

13. History of a clinically significant infection (viral, bacterial, or fungal) within 4 weeks prior to Day 1 (SV3) (including unexplained diarrhea) or clinical suspicion of infection at time of dosing. Clinically significant infections are defined as requiring systemic antibiotics, antiviral, or antifungal medication for > 7 days.

14. Prior history of/planned: lung pneumonectomy for any reason, or lung volume reduction procedures (including bronchoscopic volume reduction) for COPD. Note: Surgical biopsy, or segmentectomy, or wedge resection, or lobectomy for other diseases would not be excluded.

15. Long term oxygen therapy (a requirement for continuous oxygen therapy > 16 hours per day).

16. Use of any non-invasive positive pressure ventilation device.

17. Current diagnosis of cancer. 18. History of cancer, except if treated with apparent success with curative therapy (response duration of > 5 years).

19. A known history of severe reaction to any medication including biologic agents or human gamma globulin therapy.

20. A helminth parasitic infection diagnosed within 6 months prior to SV1 that has not been treated with, or has failed to respond to, standard of care therapy.

21. History of herpes zoster within 3 months prior to randomization (Day 1).

22. History of, or a reason to believe a participant has a history of, drug or alcohol abuse within the past 2 years prior to screening.

23. Positive hepatitis C antibody, hepatitis B virus surface antigen or hepatitis B virus core antibody, at screening.

24. A positive test for HIV or known to have HIV infection.

25. Evidence of active or untreated latent TB infection (LTBI) as evidenced by:

(a) positive IGRA test and evidence of symptoms suggestive of active TB;

(b) positive IGRA, or repeated indeterminate IGRAs, no evidence of active TB and untreated for latent infection, unable to be treated for, or declines treatment of latent TB infection;

(c) participants newly diagnosed with LTBI on initial screening could be considered for rescreening if they complete a full course of treatment for latent TB in accordance with recommended treatment guidelines prior to rescreening. In this situation, repeat IGRA test is not required after completion of treatment for LTBI ;

(d) participants with an indeterminate IGRA should undergo repeat test and if still indeterminate may only be enrolled after treatment for latent TB infection.

26. Change in smoking status in 12 weeks prior to enrolment or intention to change smoking status between enrolment and end of follow-up.

27. Participants currently receiving background therapy that is not approved by regulatory authorities in the country of study for COPD are not eligible for the study.

28. History of treatment with cardiotoxic medications (e.g. as part of cancer therapy), including thiazolidinediones.

29. Major surgery within 8 weeks prior to screening or planned inpatient surgery or hospitalization during the study period.

30. Treatment with broad spectrum antibiotic within 4 weeks prior to randomization (Day 1).

31. Donation of blood or blood products in excess of 500 mL within 3 months prior to screening.

32. History of allogeneic bone marrow transplant.

33. Treatment with allergy immunotherapy within 90 days prior to SV1. 34. Receiving any of the following prohibited concomitant medications:

(a) acute systemic (oral or injectable) corticosteroids within 4 weeks of SV1 ;

(b) any other immunosuppressive therapy (including methotrexate, cyclosporine or maintenance systemic steroid treatment) within 3 months of randomization;

(c) immunoglobulin or blood products within 4 weeks of SV1 ;

(d) live or attenuated vaccines within 4 weeks of SV1 (vaccines with adenoviral vectors that are unable to replicate, e.g. ChAdOxI, are not considered live or attenuated);

(e) interferon gamma within 3 months of randomization;

(f) investigational products within 4 months or 5 half-lives of randomization, whichever is longer;

(g) marketed biologies within 4 months or 5 half-lives of randomization, whichever is longer;

(h) any add-on therapy for COPD including theophylline. Chronic macrolide or other antibiotic therapy is allowed provided the participant has been on a stable dose/regimen for > 3 months prior to enrolment and has had at least one COPD exacerbation while on stable therapy;

(i) PDE4 inhibitors (e.g. roflumilast, Daxas®, Daliresp®) commenced within 3 months of SV1. PDE4 inhibitors are allowed provided the participant has been on a stable dose/regimen for > 3 months prior to enrolment and has had at least one COPD exacerbation while on stable therapy;

(j) vaccination against COVID-19 (either first or subsequent dose) within 30 days prior to randomization;

(k) any immunotherapy within 3 months of randomization;

(l) antitussive and mucolytic medications commenced within 4 weeks prior to SV1. Antitussive and mucolytic medications are allowed provided the participant has been on a stable therapy/regimen for greater than 4 weeks.

35. Participation in, or scheduled for, an intensive COPD rehabilitation program at any time during the intervention period (participants are permitted to be in the maintenance phase of a rehabilitation program).

36. Concurrent enrolment in another clinical study involving an investigational treatment.

37. Participant is an investigator, sub-investigator, study coordinator, or employee of the participating site or Sponsor, or is a first-degree relative of the aforementioned.

38. Inability to perform technically acceptable spirometry.

39. Pregnancy or intention to become pregnant during the study, breastfeeding, or unwillingness to use a highly effective method of contraception throughout the study in female participants of childbearing potential. 40. -

41. For imaging sub-study, participants who have received a CT scan in the 6 months prior to Screening SV1 (other than as part of previous screening for the Imaging Sub study), or who in the opinion of the investigator are not suitable for repeat CT scans.

42. For imaging sub-study, participants who are known to require a CT scan before SV14, e.g. a surveillance CT scan.

Randomisation and Administration

Screening was performed at SV1 (day-35 to -28) and SV2 (day -21 to -7). Randomisation occurred at study visit 3 (SV3 - Day 1). Participants who continued to meet eligibility criteria were randomised into treatment groups as described above. Blood samples, urine samples, efficacy assessments and safety assessments were performed in order to establish baseline.

The randomization was stratified by baseline blood eosinophils (< 300 cells/pL vs > 300 cells/pL) and background medication (includes ICS vs does not include ICS).

The first investigational product (IP) administration occurred at study visit 3 (Day 1), and comprised administering the first dose of investigational product during the treatment window. Administering 600 mg MEDI3506 required 2 x 2 mL SC injections per dose. Placebo groups were injection volume matched to the MEDI3506 groups.

At study visit 4 (Day 2), participants returned for assessment of their adherence to self-assessment efficacy reporting procedures, and safety assessments. Procedures are outlined in Table 4.

The second investigational product administration occurred at study visit 6 (Day 29 ± 3). The third investigational product administration occurred at study visit 7 (Day 57 ± 3). The fourth investigational product administration occurred at study visit 8 (Day 85 ± 3). The fifth investigational product administration occurred at study visit 9 (Day 113 ± 3). The sixth investigational product administration occurred at study visit 10 (Day 141 ± 3). The seventh and final investigational product administration occurred at study visit 11 (Day 169 ± 3).

Endpoints

The primary endpoint visit occurred at week 12, as assessed at study visit 10 (day 113 ± 4). The primary endpoint is improvement from baseline to week 12 in clinic pre-BD FEVi. Based on available data, the improvement in FEVi assumed in the sample size determination was expected to be achieved by Week 12.

Secondary endpoints included change from baseline in pre-BD and post-BD FEV1 at week 28, and change from baseline in pre-BD and post-BD FVC at week 28. For an exploratory imaging sub-group, further secondary endpoint were defined including change from baseline in mucus plug score at week 28.

Blood samples were collected from subjects for the assessment of biomarkers that are relevant to disease pathology and/or the mechanism of action of MEDI3506.

Lung Function Assessments

Lung function (FEVi and FVC) was measured by spirometry using standard equipment according to ATS/ERS guidelines (Miller et al., European Respiratory Journal 26(2): 319- 338, 2005). Spirometry testing was initiated in the morning between 6:00 AM and 11 :00 AM during the screening period and at the randomization visit (SV3). All post-randomization spirometry assessments were performed within ± 1.5 hours of the time that the randomization spirometry was performed.

For post-BD assessments, endpoint maximal BD was induced using albuterol (90 pg metered dose) or salbutamol (100 pg metered dose) with or without a spacer device up to a maximum of 4 inhalations within 30 minutes ± 15 minutes of the final pre-BD spirometry measurement. Post-BD spirometry was performed 15 to 30 minutes later.

Example 2: Investigation of Mucus Plugging in Patients in FRONTIER 4 Study

A sub-population of patients in the FRONTIER 4 study were recruited to an imaging substudy to investigate the effect of tozorakimab on various aspects of lung morphology, including mucus plugging. 50 patients in total were recruited (22 receiving tozorakimab, 28 receiving placebo), of which 11 did not complete the imaging sub-study. The results are based on the 39 patients who completed the sub-study (18 receiving tozorakimab, 21 receiving placebo.

Methods

CT Procedures

Participants in the imaging sub-study performed inspiratory and expiratory chest CT scans at weeks 0 (baseline, prior to administration of the first dose of tozorakimab/placebo) and 28 of the study.

CT scans were performed post-BD, i.e. within 60 minutes of using up to 4 inhalations of albuterol or salbutamol. CT imaging was performed using standardized, multi-detector, high-resolution CT protocols optimized for consistency, radiation exposure and image quality across scanner models. Scans were acquired at 110-120 kVp and overlapping axial images were reconstructed with a slice thickness of no more than 1.0 mm and a slice interval between 0.5 mm and 1.0 mm. Images were reconstructed using B35, B, STANDARD and FC01/FC17 reconstruction kernels for Siemens, Philips, GE and Toshiba CT scanners, respectively.

Airways were labeled and measured up to and including all segmental bronchi (Netter, supra) and two generations (G) beyond for segments RB1, RB4, RB10, LB1 and LB10 (Smith et al., Thorax 69(11): 987-96, 2014) when possible.

Mucus Plug Scoring

Mucus plugs were defined in inspiratory CT scans as opacities that completely occluded the lumen of a segmental or subsegmental airway with a visibly patent and air-containing lumen proximal and distal to the plug. Opacities were otherwise classified as airway obstructions. Lungs were divided into 18 segments based on Netter’s bronchial anatomy nomenclature (Netter, supra).

The total mucus plug score for each inspiratory CT scan was calculated as the number of these segments with at least one mucus plug, with mucus plug scores ranging from 0 to 18. Severity of mucus plugging was defined as no mucus plugs (score of 0), low (score of 1-3) and high (score of >3). The lung zone within 2 cm from the costal or diaphragmatic pleura was excluded because those airways are often too small to assess. Mucus plug scoring was conducted using a computer-assisted workflow to isolate the search zone of each of the 18 lung segments (VIDA Diagnostics, Inc).

Results

Mucus plug score was reduced in patients receiving tozorakimab compared to those receiving placebo (LS mean difference: -1.5; 80 % Cl: [-3.0, 0.0], p=0.097). This result was further supported in a post-hoc non-parametric analysis stratified by baseline score (p=0.0312; Table 1 , Figure 1). As shown in Table 1 (below), on average a greater effect in mucus plugging was seen in patients with higher baseline mucus plugging scores.

The effect of tozorakimab on lung function in the sub-group was also investigated. A clear correlation was seen between a reduction in mucus plugging and improved FVC (Figure 2). No significant correlation was observed between reduced mucus plugging and FEV1 (Figure 3). This suggests that reducing mucus plugging using tozorakimab may result in improved lung function. This would be in line with prior findings that the presence of mucus plugging causes reduced lung function.

Table 1 . Change in mucus plugging from baseline to week 28 in patients receiving tozorakimab 600 mg q4w or placebo q4w, stratified by baseline mucus plugging score.

Example 3 - Tozorakimab Reduces Mucin Secretion in 3D Epithelial Cultures from NCFBE The ability of two different anti-IL-33 antibodies to reduce mucin production was tested.

Human nasal epithelial cells (HNEC) cells from healthy controls or patients with non- cystic fibrosis bronchiectasis (NCFBE) were received from the University of Dundee. Cells were expanded in human airway cell (hAC) Culture Medium (Epithelix, EP09AM) containing 10 pM of Y27632 (Selleckchem, S1573) in a T-75 cm² flask and then frozen in cryovials.

Transwell membranes (Corning® 0.4 pM pore polyester 24-well, 3470) were coated with collagen I (StemCell, 07001 prepared in dH2O) and incubated at 37°C for between 1 and 16 hours. The collagen I solution was removed and the transwells were washed with PBS. 0.5 ml of hAC Culture Medium containing 10 pM Y27632 was included in the basolateral compartment and 0.25 ml was added to the apical region which contained cells from the cryovial at 5x10⁵/ml. Cells were kept submerged until a confluent layer formed (typically 7 days) and the media was refreshed every Monday, Wednesday and Friday. Once a confluent layer could be observed the media was removed from the basolateral and apical side and 0.5 ml of complete PneumaCult™-ALI Medium (Stemcell, 05001) containing Hydrocortisone Stock Solution (Stemcell, 07925) and Heparin Solution (Stemcell, 07980) was added to only the basolateral compartment. Cells were left to differentiate for at least four weeks with media changes in the basolateral compartment with complete PneumaCult™-ALI Medium every Monday, Wednesday and Friday.

Fully differentiated normal (healthy) cultures were not treated. Fully differentiated NCFBE cultures were left untreated or treated with 1 pg/ml tozorakimab (33_640087-7B), 1 pg/ml itepekimab (WV9KZ9PS1A; heavy chain of SEQ ID NO: 11 and light chain of SEQ ID NO: 12) or 1 pg/ml NIP228 (lgG1 isotype control) for 7 days by inclusion of treatments in the media supplied to the basal side of the culture. A media change was performed every Monday, Wednesday and Friday (containing relevant treatments).

Following 7-day treatments (Table 1) of ALI cultures, 200 pl 37°C DPBS (ThermoFisher Scientific, 14190086) was added to the apical region (Transwell surface) of each Transwell and placed in an incubator for 30 min. The apical wash was stored at -80°C for mucin analysis. Apical washes were thawed and Triton™ X-100 (Sigma Aldrich, X100- 100ML) was added to a final concentration of 0.3 % (v/v) and placed on an orbital shaker at 400 rpm for 15 mins at room temperature. The apical washes were then diluted 1:800 in DPBS (v/v) and levels of MLIC5AC (UniProt accession number P98088) were analysed using a MLIC5AC immunoassay (Novus NBP2-76703) according to manufacturer’s protocol. Concentrations were extrapolated from recombinant MLIC5AC protein standard curves.

The results are shown in Fig. 4. Untreated nasal epithelial cells from bronchiectasis patients produced much higher levels of MUC5AC than healthy nasal epithelial cells. However, treatment of nasal epithelial cells from bronchiectasis patients with tozorakimab significantly reduced MUC5AC expression, almost to the level of healthy nasal epithelial cells. Itepekimab treatment had no effect on MUC5AC expression (there was no significant difference between the levels of MUC5AC produced by bronchiectasis cells treated with itepekimab and those treated with the isotype control). The reduction in MUC5AC production by bronchiectasis airway epithelial cells in response to tozorakimab treatment suggests that tozorakimab treatment will reduce mucus viscosity, and therefore mucus plugging, in bronchiectasis treatment.

It is postulated that the effect of tozorakimab on MUC5AC expression results from its inhibition of EGFR/RAGE signalling, which itepekimab is not capable of. This suggests the increased mucin expression displayed by nasal epithelial cells from bronchiectasis patients is driven by I L-33^OX.

SEQUENCE LISTING

SEQ ID NO: 1 - Tozorakimab VHCDR1

SYAMS

SEQ ID NO: 2 - Tozorakimab VHCDR2

GISAIDQSTYYADSVKG

SEQ ID NO: 3 - Tozorakimab VHCDR3

QKFMQLWGGGLRYPFGY

SEQ ID NO: 4 - Tozorakimab VLCDR1

SGEGMGDKYAA

SEQ ID NO: 5 - Tozorakimab VLCDR2

RDTKRPS

SEQ ID NO: 6 - Tozorakimab VLCDR3

GVIQDNTGV

SEQ ID NO: 7 - Tozorakimab VH

EVQLLESGGGLVQPGGSLRLSCAASGFTFSSYAMSWVRQAPGKGLEWVSGISAIDQSTYY

ADSVKGRFTISRDNSKNTLYLQMNSLRAEDTAVYYCARQKFMQLWGGGLRYPFGYWGQG TMVTVSS

SEQ ID NO: 8 - Tozorakimab VL

SYVLTQPPSVSVSPGQTASITCSGEGMGDKYAAWYQQKPGQSPVLVIYRDTKRPSGIPERF

SGSNSGNTATLTISGTQAMDEADYYCGVIQDNTGVFGGGTKLTVL

SEQ ID NO: 9 - Tozorakimab Heavy Chain

EVQLLESGGGLVQPGGSLRLSCAASGFTFSSYAMSWVRQAPGKGLEWVSGISAIDQSTYY

ADSVKGRFTISRDNSKNTLYLQMNSLRAEDTAVYYCARQKFMQLWGGGLRYPFGYWGQG TMVTVSSASTKGPSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFP AVLQSSGLYSLSSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAP

ELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPRE

EQYNSTYRWSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPS

REEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKS

RWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

SEQ ID NO: 10 - Tozorakimab Light Chain

SYVLTQPPSVSVSPGQTASITCSGEGMGDKYAAWYQQKPGQSPVLVIYRDTKRPSGIPERF

SGSNSGNTATLTISGTQAMDEADYYCGVIQDNTGVFGGGTKLTVLGQPKAAPSVTLFPPSS

EELQANKATLVCLISDFYPGAVTVAWKADSSPVKAGVETTTPSKQSNNKYAASSYLSLTPEQ

WKSHRSYSCQVTHEGSTVEKTVAPTECS SEQ ID NO: 11 - Itepekimab Heavy Chain

EVQLVESGGNLEQPGGSLRLSCTASGFTFSRSAMNWVRRAPGKGLEWVSGISGSGGRTY

YADSVKGRFTISRDNSKNTLYLQMNSLSAEDTAAYYCAKDSYTTSWYGGMDVWGHGTTVT

VSSASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQ SSGLYSLSSVVTVPSSSLGTKTYTCNVDHKPSNTKVDKRVESKYGPPCPPCPAPEFLGGPS

VFLFPPKPKDTLMISRTPEVTCWVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNST

YRVVSVLTVLHQDWLNGKEYKCKVSNKGLPSSIEKTISKAKGQPREPQVYTLPPSQEEMTK NQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGN VFSCSVM H EALH N H YTQKSLSLSLG K

SEQ ID NO: 12 - Itepekimab Light Chain

DIQMTQSPSSVSASVGDRVTITCRASQGIFSWLAWYQQKPGKAPKLLIYAASSLQSGVPSR

FSGSGSGTDFTLTISSLQPEDFAIYYCQQANSVPITFGQGTRLEIKRTVAAPSVFIFPPSDEQL

KSGTASVVCLLNNFYPREAKVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTLTLSKAD YEKHKVYACEVTHQGLSSPVTKSFNRGEC

Claims

1. A method of reducing mucus plugging in a patient in need thereof, the method comprising administering to the patient an anti-IL-33 antibody or antigen-binding fragment thereof, wherein the antibody or fragment comprises:

(a) a heavy chain variable region comprising a VHCDR1 comprising the sequence of SEQ ID NO: 1, a VHCDR2 comprising the sequence of SEQ ID NO: 2, and a VHCDR3 comprising the sequence of SEQ ID NO: 3; and

(b) a light chain variable region comprising a VLCDR1 comprising the sequence of SEQ ID NO: 4, a VLCDR2 comprising the sequence of SEQ ID NO: 5, and a VLCDR3 comprising the sequence of SEQ ID NO: 6.

2. The method of claim 1 , wherein the patient has COPD, bronchiectasis or asthma.

3. The method of claim 2, wherein the patient has COPD and chronic bronchitis.

4. The method of any one of claims 1 to 3, wherein, prior to treatment, the patient has at least one mucus plug in at least 3 lung segments.

5. The method of any one of claims 1 to 4, wherein, prior to treatment, the patient has at least one mucus plug in at least 4 lung segments.

6. The method of any one of claims 1 to 5, wherein treatment with the anti-IL-33 antibody reduces the number of lung segments comprising a mucus plug by at least 1.

7. The method of claim 6, wherein treatment with the anti-IL-33 antibody reduces the number of lung segments comprising a mucus plug by at least 2.

8. The method of any one of claims 1 to 7, further comprising:

(i) performing a baseline scan of the patient’s lungs to determine the level of mucus plugging prior to treatment with the anti-IL-33 antibody or fragment thereof;

(ii) performing at least one follow-up scan of the patient’s lungs to determine the level of mucus plugging after at least one dose of the anti-IL-33 antibody or fragment thereof; and

(iii) comparing a follow-up scan with the baseline scan to determine the reduction in the level of mucus plugging.

9. The method of claim 8, wherein the follow-up scan is performed at least 4 weeks after administration of the first dose of the anti-IL-33 antibody or fragment thereof.

10. The method of claim 9, wherein the follow-up scan is performed at least 28 weeks after administration of the first dose of the anti-IL-33 antibody.

11. The method of any one of claims 8 to 10, wherein the scans are CT scans.

12. The method of any one of claims 1 to 11 , wherein the reduction in mucus plugging is associated with an improvement in lung function.

13. The method of claim 12, wherein the lung function is pre-bronchodilator forced vital capacity (FVC).

14. The method of any one of claims 1 to 13, wherein the patient is receiving an inhaled maintenance therapy comprising a long-acting Beta 2 agonist (LABA), a long-acting muscarinic receptor antagonist (LAMA), and/or an inhaled corticosteroid (ICS).

15. The method of claim 14, wherein the inhaled maintenance therapy comprises a LABA and a LAMA; an ICS and a LABA; or an ICS, a LABA and a LAMA.

16. The method of any one of claims 1 to 15, wherein the patient is a current smoker or a former smoker.

17. The method of claim 16, wherein the patient has a smoking history of at least 10 pack-years.

18. The method of any one of claims 1 to 17, wherein, prior to treatment, the patient has a post-bronchodilator forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio (post-bronchodilator (post-BD)-FEV1/FVC) of less than 0.70.

19. The method of any one of claims 1 to 18, wherein, prior to treatment, the patient has a post-BD FEV1 between 20 % and 80 % of predicted normal value.

20. The method of any one of claims 1 to 19, wherein the antibody or antigen-binding fragment thereof is human.

21. The method of any one of claims 1 to 20, wherein the anti-IL-33 antibody or fragment thereof comprises a heavy chain variable region comprising the sequence of SEQ ID NO: 7, or an amino acid sequence with at least 80 % sequence identity thereto; and a light chain variable region comprising the sequence of SEQ ID NO: 8, or an amino acid sequence with at least 80 % sequence identity thereto.

22. The method of claim 21 , wherein the anti-IL-33 antibody or fragment thereof comprises a heavy chain variable region comprising the sequence of SEQ ID NO: 7; and a light chain variable region comprising the sequence of SEQ ID NO: 8.

23. The method of any one of claims 1 to 22, wherein the patient is administered an anti- IL-33 antibody.

24. The method of claim 23, wherein the antibody is an IgG 1 antibody.

25. The method of claim 24, wherein the anti-IL-33 antibody is tozorakimab.

26. The method of any one of claims 1 to 22, wherein the patient is administered an antigen-binding fragment of an anti-IL-33 antibody.

27. The method of claim 26, wherein the antigen-binding fragment is a Fab, F(ab')2, Fab', Fv, scFv, diabody, triabody or tetrabody.

28. The method of any one of claims 1 to 27, wherein the anti-IL-33 antibody or antigenbinding fragment thereof is administered to the patient subcutaneously.

29. The method of any one of claims 1 to 28, wherein the anti-IL-33 antibody or antigenbinding fragment thereof is administered to the patient at a dose of about 200 mg to about 800 mg every 1 to 4 weeks.

30. The method of claim 29, wherein the anti-IL-33 antibody or antigen-binding fragment thereof is administered to the patient at a dose of about 300 mg to about 600 mg every 2 to

4 weeks.

31. The method of claim 30, wherein the anti-IL-33 antibody or antigen-binding fragment thereof is administered to the patient at a dose of:

(i) 300 mg every 2 weeks; (ii) 300 mg every 4 weeks; or

(iii) 600 mg every 4 weeks.

32. The method of any one of claims 1 to 31 , wherein the anti-IL-33 antibody or antigenbinding fragment thereof is administered to the patient over a course of therapy lasting at least 6 months.

33. An anti-IL-33 antibody or antigen-binding fragment thereof for use in a method of reducing mucus plugging in a patient, the method comprising administering to the patient the anti-IL-33 antibody or antigen-binding fragment thereof, wherein the antibody or fragment comprises:

(a) a heavy chain variable region comprising a VHCDR1 comprising the sequence of SEQ ID NO: 1, a VHCDR2 comprising the sequence of SEQ ID NO: 2, and a VHCDR3 comprising the sequence of SEQ ID NO: 3; and

(b) a light chain variable region comprising a VLCDR1 comprising the sequence of SEQ ID NO: 4, a VLCDR2 comprising the sequence of SEQ ID NO: 5, and a VLCDR3 comprising the sequence of SEQ ID NO: 6.

34. The anti-IL-33 antibody or antigen-binding fragment thereof for use according to claim 33, wherein the method, patient and/or antibody or antigen-binding fragment thereof are as defined in any one of claims 2 to 32.

35. Use of an anti-IL-33 antibody or antigen-binding fragment thereof in the manufacture of a medicament for treating mucus plugging in a patient, the treatment comprising administering to the patient the anti-IL-33 antibody or antigen-binding fragment thereof, wherein the antibody or fragment comprises:

(a) a heavy chain variable region comprising a VHCDR1 comprising the sequence of SEQ ID NO: 1, a VHCDR2 comprising the sequence of SEQ ID NO: 2, and a VHCDR3 comprising the sequence of SEQ ID NO: 3; and

(b) a light chain variable region comprising a VLCDR1 comprising the sequence of SEQ ID NO: 4, a VLCDR2 comprising the sequence of SEQ ID NO: 5, and a VLCDR3 comprising the sequence of SEQ ID NO: 6.

36. Use of an anti-IL-33 antibody or antigen-binding fragment thereof for treating mucus plugging in a patient, the treatment comprising administering to the patient the anti-IL-33 antibody or antigen-binding fragment thereof, wherein the antibody or fragment comprises: (a) a heavy chain variable region comprising a VHCDR1 comprising the sequence of SEQ ID NO: 1, a VHCDR2 comprising the sequence of SEQ ID NO: 2, and a VHCDR3 comprising the sequence of SEQ ID NO: 3; and

(b) a light chain variable region comprising a VLCDR1 comprising the sequence of SEQ ID NO: 4, a VLCDR2 comprising the sequence of SEQ ID NO: 5, and a VLCDR3 comprising the sequence of SEQ ID NO: 6.

37. The use of claim 35 or 36, wherein the treatment, patient and/or antibody or antigenbinding fragment thereof are as defined in any one of claims 2 to 32.

38. A pharmaceutical composition comprising an anti-IL-33 antibody or antigen-binding fragment thereof for use in a method of reducing mucus plugging in a patient, the method comprising administering to the patient the composition comprising the anti-IL-33 antibody or antigen-binding fragment thereof, wherein the antibody or fragment comprises:

(a) a heavy chain variable region comprising a VHCDR1 comprising the sequence of SEQ ID NO: 1, a VHCDR2 comprising the sequence of SEQ ID NO: 2, and a VHCDR3 comprising the sequence of SEQ ID NO: 3; and

(b) a light chain variable region comprising a VLCDR1 comprising the sequence of SEQ ID NO: 4, a VLCDR2 comprising the sequence of SEQ ID NO: 5, and a VLCDR3 comprising the sequence of SEQ ID NO: 6.

39. The pharmaceutical composition of claim 38, wherein the method, patient and/or antibody or antigen-binding fragment thereof are as defined in any one of claims 2 to 32.