TW202310872A - Methods for treating hyperlipidemia in diabetic patients by administering a pcsk9 inhibitor - Google Patents

Abstract

Provided are methods for treating high cardiovascular risk patients with hypercholesterolemia and type 1 or type 2 diabetes mellitus receiving insulin therapy. These methods generally comprise administering to a patient a pharmaceutical composition comprising an antibody or antigen binding fragment, thereof, which specifically binds hPCSK9 antibody, in combination with insulin therapy.

Description

Method for treating hyperlipidemia in diabetic patients by administering PCSK9 inhibitor 【Related applications】

This application asserts U.S. Provisional Patent Application No. 62/517,672 filed June 9, 2017, U.S. Provisional Patent Application No. 62/532,162 filed July 13, 2017, and European Patent Application No. 62/532,162 filed May 4, 2018. Benefit of priority of patent application number 18305565.6. The content of each of these related applications is hereby incorporated by reference in its entirety.

The present invention is in the field of therapeutic treatment of diseases or conditions associated with elevated lipid or lipoprotein levels. More specifically, the present invention relates to the treatment of diabetic patients with hyperlipidemia, including hypercholesterolemia, with PCSK9 inhibitors.

Hyperlipidemia is a general term that includes diseases and conditions characterized by or associated with elevated levels of lipids and/or lipoproteins in the blood. Hyperlipidemia includes hypercholesterolemia, hypertriglyceridemia, mixed hyperlipidemia, and elevated lipoprotein a (Lp(a)). A particularly prevalent form of hyperlipidemia in many populations is hypercholesterolemia.

Hypercholesterolemia, particularly elevated levels of low-density lipoprotein (LDL) cholesterol (LDL-C), constitutes a major risk for the development of atherosclerosis and coronary heart disease (CHD) (Sharrett et al., 2001, Circulation 104: 1108-1113). LDL cholesterol was identified as the primary target of cholesterol-lowering therapy and accepted as a valid surrogate treatment endpoint. A large number of studies have confirmed that reducing LDL-C levels can reduce the risk of CHD, and there is a strong direct relationship between LDL-C levels and CHD events; CVD) Mortality and morbidity were reduced by 22%. Greater reductions in LDL-C yielded greater reductions in CHD events, and data from intensive comparisons with standard statin therapy suggest that lower LDL-C levels are associated with greater reductions in patients at very high cardiovascular (CV) risk. The greater the benefit.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with type 1 (T1) or type 2 (T2) diabetes mellitus (DM), and insulin-treated diabetic patients have an even higher CV risk. Furthermore, the presence of comorbid DM in patients with atherosclerotic CVD (ASCVD) significantly increases the risk of CV events. Several studies and meta-analyses have shown that lowering LDL-C with statins leads to a significant reduction in CV events in patients with DM, and use of concomitant ezetimibe leads to a further reduction in CV risk associated with additional LDL-C lowering. However, even with currently available treatments, many patients with DM continue to have persistent lipid abnormalities and thus are exposed to residual risk of CV events.

Current LDL-C-lowering drugs include proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, such as anti-PCSK9 antibodies. Although anti-PCSK9 antibodies have been extensively studied clinically, the efficacy and safety of alirocumab in the diabetic population is not fully understood. Accordingly, there is a need in the art to identify therapeutic regimens for anti-PCSK9 antibodies that provide optimal efficacy and safety for the treatment of hypercholesterolemia in insulin-treated diabetic patients at high CV risk.

The present disclosure provides methods for treating hypercholesterolemia in patients with diabetes mellitus (DM) receiving insulin therapy. In certain embodiments, the method comprises administering one or more doses of an antibody or antigen-binding fragment thereof that specifically binds human PCSK9 to a patient with hypercholesterolemia and diabetes. In certain embodiments, the patient has high cardiovascular risk. In certain embodiments, the patient is receiving concomitant antidiabetic therapy in addition to insulin therapy.

According to one aspect, the method comprises a method for treating hypercholesterolemia in a patient with type 1 diabetes mellitus (T1DM), the method comprising: (a) selecting a high cardiovascular risk patient receiving insulin therapy, who suffers from With (i) T1DM, and (ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and (b) the patient was administered 75 mg, 150 mg, or 300 mg mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9), wherein the patient is receiving concomitant insulin therapy.

In certain embodiments, 75 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. In other embodiments, 150 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. In other embodiments, 300 mg of the antibody or antigen-binding fragment is administered to the patient every four weeks.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain CDRs comprising the HCVR/LCVR amino acid sequence pair of SEQ ID NO: 1/6. In certain embodiments, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOs: 2, 3, and 4, and the three light chains set forth in SEQ ID NOs: 7, 8, and 10 CDR. In certain embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 1, and a light chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 6. Chain Variable Region (LCVR). In certain embodiments, the antibody or antigen-binding fragment thereof is associated with an antibody or antigen-binding fragment thereof comprising an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 6 Competition combined. In certain embodiments, the antibody or antigen-binding fragment thereof binds to an epitope of PCSK9 that is associated with an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and the amino acid of SEQ ID NO: 6 The sequence of the LCVR antibody binds to the same epitope. In certain embodiments, the antibody or antigen-binding fragment thereof binds to an epitope of PCSK9 that is associated with an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and the amino acid of SEQ ID NO: 6 The sequences of the LCVR antibody epitopes overlap.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain CDR amino acid sequences having SEQ ID NO: 86, 87, 88, 90, 91 and 92. In certain embodiments, the antibody or antigen-binding fragment thereof comprises an HCVR having an amino acid sequence at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO: 85, and an LCVR having an amino acid sequence at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO:89.

In certain embodiments, the antibody or antigen-binding fragment thereof is selected from the group consisting of alirocumab, evolocumab, bococizumab, Lodelcizumab, ralpancizumab, and LY3015014. In certain embodiments, the antibody or antigen-binding fragment thereof is alicumab.

In certain embodiments, the methods disclosed herein further comprise: (c) if, for example, after 8 weeks, the LDL-C level in the patient is below a threshold level, administering to the patient about every two weeks one or more Up to 75 mg of the antibody or antigen-binding fragment thereof, or if, for example, after 8 weeks, the LDL-C level in the patient is greater than or equal to the threshold level, one or more of the following doses of 150 mg are administered about every two weeks The antibody or antigen-binding fragment thereof. In certain embodiments, the threshold level is 70 mg/dL.

In certain embodiments, the methods disclosed herein further comprise: (c) if, for example, after 8 weeks, the LDL-C level in the patient is below a threshold level, administering to the patient about every four weeks one or more 300 mg of the antibody or antigen-binding fragment thereof, or if, for example, after 8 weeks, the LDL-C level in the patient is greater than or equal to a threshold level, one or more doses of 150 mg of The antibody or antigen-binding fragment thereof. In certain embodiments, the threshold level is 70 mg/dL.

In certain embodiments, the antibody or antigen-binding fragment thereof is administered subcutaneously.

In certain embodiments, the patient further receives concomitant lipid-modifying therapy (LMT). In certain embodiments, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile acid sequestrants. In certain embodiments, the LMT is statin therapy. In certain embodiments, the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin statins (lovastatin), fluvastatin (fluvastatin), pitavastatin (pitavastatin), and cerivastatin (cerivastatin). In certain embodiments, the statin therapy is maximally tolerated dose statin therapy. In certain embodiments, the cholesterol absorption inhibitor is ezetimibe. In certain embodiments, the patient is statin intolerant.

In certain embodiments, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart and basal insulin. In certain embodiments, the patient further receives additional concomitant antidiabetic therapy in addition to insulin therapy. In some embodiments, Additional concomitant antidiabetic therapy is selected from the group consisting of glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide (GIP) receptor agonists or antagonists, growth hormone releasing hormone antagonists or inverse agonists, xenin, xenin analogs, biguanides, sulfonylureas, meglitinides, thiazolidines Diketones, DPP-4 inhibitors, α-glucosidase inhibitors, sodium-dependent glucose transporter 2 (SGLT-2) inhibitors, SGLT-1 inhibitors, peroxisome proliferator-activated receptor ( PPAR-) (α, γ, or α/γ) agonists or modulators, amylin, amylin analogs, G protein-coupled receptor 119 (GPR119) agonists, GPR40 agonists, GPR120 agonists agonists, GPR142 agonists, systemic or poorly absorbed TGR5 agonists, diabetes immunotherapy, anti-inflammatory agents for the treatment of metabolic syndrome and diabetes, adenosine monophosphate-activated protein kinase (AMPK) stimulator stimulator , inhibitor of 11-β-hydroxysteroid dehydrogenase 1, activator of glucokinase, inhibitor of diacylglycerol O-acyltransferase (DGAT), regulator of glucose transporter-4, growth inhibitor receptor 3 agonists, lipid-lowering agents, and combinations thereof.

In certain embodiments, the antibody or antigen-binding fragment thereof reduces the patient's LDL-C levels, eg, by at least 30%, 35%, 40%, or 45%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces the patient's non-HDL-C levels, eg, by at least 25%, 30%, 35% or 40%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces the patient's apolipoprotein C3 (ApoC3) levels (e.g., by at least about 6.0%, about 6.5%, about 7.0% after 12 or 24 weeks of treatment or about 7.5%). In certain embodiments, the antibody or antigen-binding fragment thereof reduces the number of lipoprotein particles in the patient (e.g., by at least about 20%, about 30%, about 40%, or about 50%). In other embodiments, the antibody or antigen-binding fragment thereof reduces the size of lipoprotein particles in the patient (e.g., by at least about 1.5%, about 2%, about 2.5%, or about 3%).

In certain embodiments, the antibody or antigen-binding fragment thereof: (a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or (b) does not affect the patient's fasting blood glucose (FPG) level.

According to another aspect, the method comprises a method for treating hypercholesterolemia in a patient with type 1 diabetes (T1DM), the method comprising:

(a) select insulin-treated high cardiovascular risk patients with (i) T1DM, and (ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and

(b) administering to the patient 75 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) every two weeks; and

(c) if, for example, after 8 weeks, the LDL-C level in the patient is below 70 mg/dL, administering to the patient about every two weeks one or more doses of 75 mg of the antibody or antigen-binding fragment thereof, Or if, for example, after 8 weeks, the LDL-C level in the patient is greater than or equal to 70 mg/dL, then administering one or more doses of 150 mg of the antibody or antigen-binding fragment thereof about every two weeks, wherein the antibody or The antigen-binding fragment thereof comprises HCVR having the amino acid sequence of SEQ ID NO: 1 and LCVR having the amino acid sequence of SEQ ID NO: 6, and wherein the patient receives concomitant insulin therapy.

According to another aspect, the method comprises a method for treating hypercholesterolemia in a patient with type 1 diabetes (T1DM), the method comprising:

(a) select insulin-treated high cardiovascular risk patients with (i) T1DM, and (ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and

(b) administering to the patient 300 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) every four weeks; and

(c) if, for example, after 8 weeks, the LDL-C level in the patient is below a threshold level, administering to the patient one or more doses of 300 mg of the antibody or antigen-binding fragment thereof about every four weeks, or if , for example, after 8 weeks, the LDL-C level in the patient is greater than or equal to the threshold level, administering one or more doses of 150 mg of the antibody or antigen-binding fragment thereof about every two weeks,

wherein the antibody or antigen-binding fragment thereof comprises HCVR having the amino acid sequence of SEQ ID NO: 1, and LCVR having the amino acid sequence of SEQ ID NO: 6, and wherein the patient is receiving concomitant insulin therapy. In one embodiment, the threshold level is 15 mg/dL. In another embodiment, the threshold level is 25 mg/dL.

According to another aspect, the method comprises a method for treating hypercholesterolemia in a patient with type 2 diabetes (T2DM), the method comprising:

(a) select insulin-treated high cardiovascular risk patients with (i) T2DM, and (ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and

(b) administering 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) to the patient, wherein the patient receives concomitant insulin therapy.

In certain embodiments, 75 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. In other embodiments, 150 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. In other embodiments, 300 mg of the antibody or antigen-binding fragment is administered to the patient every four weeks.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain CDRs comprising the HCVR/LCVR amino acid sequence pair of SEQ ID NO: 1/6. In certain embodiments, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOs: 2, 3, and 4, and the three light chains set forth in SEQ ID NOs: 7, 8, and 10 CDR. In certain embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 1, and a light chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 6. Chain Variable Region (LCVR). In certain embodiments, the antibody or antigen-binding fragment thereof is associated with an antibody or antigen-binding fragment thereof comprising an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 6 Competition combined. In certain embodiments, the antibody or antigen-binding fragment thereof binds to an epitope of PCSK9 that is associated with an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and the amino acid of SEQ ID NO: 6 The sequence of the LCVR is identical to the epitope of the antibody. In certain embodiments, the antibody or antigen-binding fragment thereof binds to an epitope of PCSK9 that is associated with an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and the amino acid of SEQ ID NO: 6 The sequences of the LCVR antibody epitopes overlap.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) and a light chain variable region (LCVR) comprising the amino acid sequences set forth in SEQ ID NO: 85 and 89, respectively complementarity determining regions (CDRs). In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain CDR amino acid sequences having SEQ ID NO: 86, 87, 88, 90, 91 and 92. In certain embodiments, the antibody or antigen-binding fragment thereof comprises an amino acid sequence having an amino acid sequence at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO: 85 HCVR, and LCVR having an amino acid sequence at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO:89.

In certain embodiments, the antibody or antigen-binding fragment thereof is selected from the group consisting of alirocumab, evoclizumab, bococizumab, rodixizumab, ralpancizumab, and LY3015014. In certain embodiments, the antibody or antigen-binding fragment thereof is alicumab.

In certain embodiments, the methods disclosed herein further comprise: (c) if the LDL-C level in the patient is below a threshold level, administering to the patient about every two weeks one or more doses of 75 mg of the The antibody or antigen-binding fragment thereof, or, if the LDL-C level in the patient is greater than or equal to the threshold level, one or more doses of the antibody or antigen-binding fragment thereof of 150 mg about every two weeks. In certain embodiments, the threshold level is 70 mg/dL.

In certain embodiments, the methods disclosed herein further comprise: (c) if, for example, after 8 weeks, the LDL-C level in the patient is below a threshold level, administering to the patient about every four weeks one or more 300 mg of the antibody or antigen-binding fragment thereof, or if, for example, after 8 weeks, the LDL-C level in the patient is greater than or equal to the threshold level, one or more doses of 150 mg administered approximately every two weeks The antibody or antigen-binding fragment thereof. In certain embodiments, the threshold level is 70 mg/dL.

In certain embodiments, the antibody or antigen-binding fragment thereof is administered subcutaneously.

In certain embodiments, the patient further receives concomitant lipid modification therapy (LMT). In certain embodiments, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile acid sequestrants. In certain embodiments, the LMT is statin therapy. In certain embodiments, the statin is selected from the group consisting of: atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cetirizine Vastatin. In certain embodiments, the statin therapy is a maximally tolerated dose of statin therapy. In certain embodiments, the cholesterol absorption inhibitor is ezetimibe.

In certain embodiments, the patient is statin intolerant.

In certain embodiments, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and insulin basal.

In certain embodiments, the patient further receives concomitant antidiabetic therapy in addition to insulin therapy. In certain embodiments, the additional antidiabetic therapy is selected from the group consisting of glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptides, glucagon receptor agonists or antagonists, Glucose-dependent insulinotropic polypeptide (GIP) receptor agonists or antagonists, ghrelin antagonists or inverse agonists, xenin, xenin analogs, biguanides, sulfonylureas, meglitinides , thiazolidinediones, DPP-4 inhibitors, alpha-glucosidase inhibitors, sodium-dependent glucose transporter 2 (SGLT-2) inhibitors, SGLT-1 inhibitors, peroxisome proliferator activation Receptor (PPAR-) (alpha, gamma, or alpha/gamma) agonists or modulators, amylin, amylin analogs, G protein-coupled receptor 119 (GPR119) agonists, GPR40 agonists , GPR120 agonists, GPR142 agonists, systemic or poorly absorbed TGR5 agonists, diabetes immunotherapy, anti-inflammatory agents for the treatment of metabolic syndrome and diabetes, adenosine monophosphate-activated protein kinase (AMPK) stimulation inhibitor of 11-β-hydroxysteroid dehydrogenase 1, activator of glucokinase, inhibitor of diacylglycerol O-acyltransferase (DGAT), regulator of glucose transporter-4, growth Statin receptor 3 agonists, lipid-lowering agents, and combinations thereof.

In certain embodiments, the antibody or antigen-binding fragment thereof reduces the patient's LDL-C levels, eg, by at least 30%, 35%, 40%, or 45%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces non-HDL-C levels in the patient, eg, by at least 20%, 25%, 30%, or 35%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces the patient's apolipoprotein C3 (ApoC3) levels (e.g., by at least about 6.0%, about 6.5%, about 7.0% after 12 or 24 weeks of treatment or about 7.5%). In certain embodiments, the antibody or antigen-binding fragment thereof reduces the number of lipoprotein particles in the patient (e.g., by at least about 20%, about 30%, about 40%, or about 50%). In other embodiments, the antibody or antigen-binding fragment thereof reduces the size of lipoprotein particles in the patient (e.g., by at least about 1.5%, about 2%, about 2.5%, or about 3%).

In certain embodiments, the antibody or antigen-binding fragment thereof: (a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or (b) does not affect the patient's fasting blood glucose (FPG) level.

According to another aspect, the method comprises a method for treating hypercholesterolemia in a patient with type 2 diabetes (T2DM), the method comprising:

(a) select insulin-treated high cardiovascular risk patients with (i) T2DM, and (ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy;

(b) administering to the patient 75 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) every two weeks; and

(c) if, for example, after 8 weeks, the LDL-C level in the patient is below 70 mg/dL, administering to the patient about every two weeks one or more doses of 75 mg of the antibody or antigen-binding fragment thereof, or if, e.g., after 8 weeks, the LDL-C level in the patient is greater than or equal to 70 mg/dL, administering one or more doses of 150 mg of the antibody or antigen-binding fragment thereof about every two weeks,

wherein the antibody or antigen-binding fragment thereof comprises HCVR having the amino acid sequence of SEQ ID NO: 1, and LCVR having the amino acid sequence of SEQ ID NO: 6, and wherein the patient is receiving concomitant insulin therapy.

According to another aspect, the method comprises a method for treating hypercholesterolemia in a patient with type 2 diabetes (T2DM), the method comprising:

(a) select insulin-treated high cardiovascular risk patients with (i) T2DM, and (ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy;

(b) administering to the patient 300 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) every four weeks; and

(c) if, for example, after 8 weeks, the LDL-C level in the patient is above a threshold level, administering to the patient one or more doses of 300 mg of the antibody or antigen-binding fragment thereof about every four weeks, or if , for example, after 8 weeks, the LDL-C level in the patient is lower than or equal to the threshold level, then administering one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof about every two weeks,

wherein the antibody or antigen-binding fragment thereof comprises HCVR having the amino acid sequence of SEQ ID NO: 1, and LCVR having the amino acid sequence of SEQ ID NO: 6, and wherein the patient is receiving concomitant insulin therapy. In one embodiment, the threshold level is 15 mg/dL. In another embodiment, the threshold level is 25 mg/dL.

According to another aspect, the method comprises a method for treating hypercholesterolemia in a patient with T2DM and atherosclerotic cardiovascular disease (ASCVD), the method comprising:

(a) select insulin-treated high cardiovascular risk patients with (i) T2DM, (ii) ASCVD, and (iii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and

(b) administering 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) to the patient, wherein the patient receives concomitant insulin therapy.

In certain embodiments, the ASCVD is defined as coronary heart disease (CHD), ischemic stroke, or peripheral arterial disease. In certain embodiments, the CHD comprises acute myocardial infarction, asymptomatic myocardial infarction, and unstable angina.

In certain embodiments, 75 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. In certain embodiments, 150 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. In certain embodiments, 300 mg of the antibody or antigen-binding fragment is administered to the patient every four weeks.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain CDRs comprising the HCVR/LCVR amino acid sequence pair of SEQ ID NO: 1/6. In certain embodiments, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOs: 2, 3, and 4, and the three heavy chain CDRs set forth in SEQ ID NOs: 7, 8, and 10 Light chain CDRs. In certain embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 1, and a light chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 6. Chain Variable Region (LCVR). In certain embodiments, the antibody or antigen-binding fragment thereof binds to an epitope of PCSK9 that is associated with an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and the amino acid of SEQ ID NO: 6 The sequence of the LCVR antibody binds to the same epitope. In certain embodiments, the antibody or antigen-binding fragment thereof binds to an epitope of PCSK9 that is associated with an HCVR comprising the amino acid sequence of SEQ ID NO: 1 and the amino acid of SEQ ID NO: 6 The sequences of the LCVR antibody epitopes overlap.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) and a light chain variable region (LCVR) comprising the amino acid sequences set forth in SEQ ID NO: 85 and 89, respectively complementarity determining regions (CDRs). In certain embodiments, the antibody or antigen-binding tablet thereof The segment comprises heavy and light chain CDR amino acid sequences having SEQ ID NO:86, 87, 88, 90, 91 and 92. In certain embodiments, the antibody or antigen-binding fragment thereof comprises an HCVR having an amino acid sequence at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO: 85, and an LCVR having an amino acid sequence at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO:89.

In certain embodiments, the antibody or antigen-binding fragment thereof is selected from the group consisting of alirocumab, evoclizumab, bococizumab, rodixizumab, ralpancizumab, and LY3015014. In certain embodiments, the antibody or antigen-binding fragment thereof is alicumab.

In certain embodiments, the method further comprises: (c) if the LDL-C level in the patient is below a threshold level, administering to the patient about every two weeks one or more doses of 75 mg of the antibody or An antigen-binding fragment thereof, or if the LDL-C level in the patient is greater than or equal to the threshold level, one or more doses of 150 mg of the antibody or antigen-binding fragment thereof are administered about every two weeks.

In certain embodiments, the method further comprises: (c) if the LDL-C level in the patient is below a threshold level, administering to the patient one or more doses of 300 mg of the antibody, or The antigen-binding fragment, or if the LDL-C level in the patient is greater than or equal to the threshold level, one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof are administered about every two weeks.

In certain embodiments, the threshold level is 70 mg/dL.

In certain embodiments, the antibody or antigen-binding fragment thereof is administered subcutaneously.

In certain embodiments, the patient further receives concomitant lipid modification therapy (LMT). In certain embodiments, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile acid sequestrants. In certain embodiments, the LMT is statin therapy. In certain embodiments, the statin is selected from the group consisting of: atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cetirizine Vastatin. In certain embodiments, the statin therapy is a maximally tolerated dose of statin therapy. In certain embodiments, the cholesterol absorption inhibitor is ezetimibe.

In certain embodiments, the patient is statin intolerant.

In certain embodiments, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and insulin basal. In certain embodiments, the patient further receives concomitant antidiabetic therapy in addition to insulin therapy. In certain embodiments, the additional antidiabetic therapy is selected from the group consisting of glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptides, glucagon receptor agonists or antagonists, Glucose-dependent insulinotropic polypeptide (GIP) receptor agonists or antagonists, ghrelin antagonists or inverse agonists, xenin, xenin analogs, biguanides, sulfonylureas, meglitinides , thiazolidinediones, DPP-4 inhibitors, alpha-glucosidase inhibitors, sodium-dependent glucose transporter 2 (SGLT-2) inhibitors, SGLT-1 inhibitors, peroxisome proliferator activation Receptor (PPAR-) (alpha, gamma, or alpha/gamma) agonists or modulators, amylin, amylin analogs, G protein-coupled receptor 119 (GPR119) agonists, GPR40 agonists , GPR120 agonists, GPR142 agonists, systemic or poorly absorbed TGR5 agonists, diabetes immunotherapy, anti-inflammatory agents for the treatment of metabolic syndrome and diabetes, adenosine monophosphate-activated protein kinase (AMPK) stimulation inhibitor of 11-β-hydroxysteroid dehydrogenase 1, activator of glucokinase, inhibitor of diacylglycerol O-acyltransferase (DGAT), regulator of glucose transporter-4, growth Statin receptor 3 agonists, lipid-lowering agents, and combinations thereof.

In certain embodiments, the antibody or antigen-binding fragment thereof reduces the patient's LDL-C levels, eg, by at least 30%, 35%, 40%, or 45%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces the patient's non-HDL-C levels, eg, by at least 20%, 25%, 30%, 35%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces ApoC3 levels in the patient. In certain embodiments, the antibody or antigen-binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient. In certain embodiments, the antibody or antigen-binding fragment thereof:

(a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or

(b) Does not affect the patient's fasting plasma glucose (FPG) level.

According to another aspect, the method comprises a method for treating hypercholesterolemia in a patient with T2DM and ASCVD comprising:

(a) select insulin-treated high cardiovascular risk patients with (i) T2DM, (ii) ASCVD, and (iii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy;

(b) administering to the patient 75 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) every two weeks, and

(c) administering to the patient one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof about every two weeks if the LDL-C level in the patient is below 70 mg/dL, or if the patient has LDL-C levels greater than or equal to 70 mg/dL, administering one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof approximately every two weeks,

wherein the antibody or antigen-binding fragment thereof comprises HCVR having the amino acid sequence of SEQ ID NO: 1, and LCVR having the amino acid sequence of SEQ ID NO: 6, and wherein the patient is receiving concomitant insulin therapy.

Other embodiments will become apparent from a review of the detailed description that follows.

Figure 1 is a diagram illustrating the general design of the main phases of the study described in Example 2 herein. The study included a screening period, a double-blind treatment period and a safety observation period.

Figure 2 is a graph showing the LS mean (+/- SE) of the percent change from baseline in LDL-C levels calculated according to the IVRS in the ITT population of patients with type 1 diabetes. Least squares (LS) means and standard errors (SE) were obtained from repeated measures mixed effects model (MMRM) analysis. The model includes fixed categorical effects for treatment group, randomization strata by IVRS, time point, interaction of treatment group with time point, interaction of strata with time point, interaction of treatment group with strata, treatment group Continuing fixed covariates with the interaction of stratum and time point, as well as the calculated LDL-C value at baseline and the interaction of baseline value with time point. The MMRM model was performed on all patients in the ITT population (ie type 1 and type 2 diabetic patients).

Figure 3 is a graph showing the LS mean (+/- SE) of the percent change from baseline in LDL-C levels calculated according to the IVRS in the ITT population of patients with type 2 diabetes. Least squares (LS) means and standard errors (SE) were obtained from repeated measures mixed effects model (MMRM) analysis. The model included fixed categorical effects for treatment group, randomization strata by IVRS, time point, interaction of treatment group by time point, interaction of stratum by time point, interaction of treatment group by stratum, treatment group by stratum and Interaction by time point, and continuous fixed covariates for calculated LDL-C value at baseline and interaction between baseline and time point. The MMRM model was performed on all patients in the ITT population (ie type 1 and type 2 diabetic patients).

Figure 4 is a graph showing the percent change from baseline to week 24 for non-HDL-C, LDL-C, ApoB and LDL-PN in the ITT population with type 2 diabetes and ASCVD.

Figure 5 is a graph showing the percentage of individuals achieving non-HDL-C <100 mg/dL, LDL-C <70 mg/dL and ApoB <80 mg/dL at week 24 in the ITT population with type 2 diabetes and ASCVD.

This method is not limited to the particular methodology and experimental conditions described, as these can vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the methods of the present invention will be limited only by the appended patent claims.

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art. As used herein, the term "about", when used in reference to a specifically recited value, means that the value may vary by no more than 1% from the recited value. For example, as used herein, the expression "about 100" includes 99 and 101 and all values therebetween (eg, 99.1, 99.2, 99.3, 99.4, etc.).

Although any methods and materials similar or equivalent to those described herein can be used, the preferred methods and materials are now described. All publications mentioned herein are incorporated by reference in their entirety.

Method for treating a patient with hypercholesterolemia and diabetes during insulin therapy

Methods and compositions for treating diabetic patients with hypercholesterolemia during insulin therapy are provided. According to certain embodiments, the methods result in a reduction in lipoprotein levels (eg, LDL-C and/or Lp(a)) in the serum of these patients.

The disclosure also provides PCSK9 inhibitors (e.g., antibodies or antigen-binding fragments thereof or comprising PCSK9 inhibitors that specifically bind to PCSK9 (e.g., human PCSK9) A composition for the treatment of diabetic patients with hypercholesterolemia during insulin therapy. In certain embodiments, a PCSK9 inhibitor or composition is useful in reducing the levels of lipoproteins (eg, LDL-C and/or Lp(a)) in the serum of such patients.

As used herein, the term "lipoprotein" means a biomolecular particle containing both proteins and lipids. Examples of lipoproteins include, for example, low density lipoprotein (LDL), very low density lipoprotein (VLDL), intermediate density lipoprotein (IDL), and lipoprotein (a) (Lp(a)).

Diabetes mellitus, often simply called diabetes, is a group of metabolic diseases in which a person has high blood sugar levels because the body does not produce enough insulin, or because the cells do not respond to the insulin that is produced. The most common types of diabetes are: (1) type 1 diabetes, in which the body cannot produce insulin; (2) type 2 diabetes, in which the body does not use insulin properly, with increasing insulin deficiency over time; (3) Gestational diabetes, in which a woman develops diabetes as a result of her pregnancy. All forms of diabetes increase the risk of long-term complications, which often develop over many years. Most of these long-term complications are based on damage to blood vessels and can be divided into two categories: "macrovascular" disease caused by atherosclerosis of large vessels and "microvascular" disease caused by damage to small blood vessels. Examples of macrovascular disease conditions are ischemic heart disease, myocardial infarction, stroke and peripheral vascular disease. Examples of microvascular diseases are diabetic retinopathy, diabetic nephropathy and diabetic neuropathy.

According to certain embodiments, the patient to be treated has type 1 diabetes (T1DM) or type 2 diabetes (T2DM) and is receiving insulin therapy. In certain embodiments, the patient has been diagnosed with T1DM or T2DM for at least one year. In certain embodiments, the patient was diagnosed with T1DM before the age of 30. In certain embodiments, the T1DM patient has a C-peptide level of less than 0.2 pmol/mL. In certain embodiments, the patient has a glycosylated hemoglobin (HbA1c) level of less than 10%.

According to certain embodiments, the patient to be treated has hypercholesterolemia inadequately controlled by lipid modification therapy (LMT). Hypercholesterolemia is considered insufficiently controlled by LMT if the patient's serum LDL-C concentration does not drop to a generally accepted medically acceptable level, such as less than 70 mg/dL, after at least 4 weeks of LMT (taking into account the patient's coronary heart disease relative risk). In certain embodiments, LMT is maximally tolerated statin therapy. As used herein, "maximally tolerated statin therapy" means the highest dose of statin that can be administered to a patient without causing unacceptable adverse side effects in that patient. For example, the methods disclosed herein include treating people with high cholesterol Alcoholism Patients with T1DM or T2DM whose hypercholesterolemia is not adequately controlled by a daily dose of a statin selected from the group consisting of: atorvastatin (including atorvastatin + ezetimibe) , rosuvastatin, cerivastatin, pitavastatin, fluvastatin, lovastatin, simvastatin (including simvastatin + ezetimibe), pravastatin, and combinations thereof. In certain embodiments, the patient does not receive concomitant statin therapy if the patient is intolerant to the treatment. For example, statin-intolerant patients may have skeletal muscle-related symptoms, such as aches, pains, weakness, that begin or increase during statin therapy and cease when statin therapy is stopped, other than symptoms due to sprains or trauma or cramps.

patient selection

The methods and compositions of the invention are useful for treating patients with hypercholesterolemia and diabetes who are receiving insulin therapy. A patient to be treated may also exhibit one or more additional selection criteria. For example, a patient may be selected for treatment if the patient has a calculated LDL-C level greater than or equal to 70 mg/dL, 100 mg/dL, or 130 mg/dL. The patient may be treated with a maximally tolerated dose of statin optionally in combination with at least one other lipid-modifying therapy (LMT) for at least 4 weeks, or where if the patient is statin intolerant, the patient has been treated with an optimal dose of at least one non- Statin LMT therapy continued for at least 4 weeks. The maximum tolerated dose of a statin can be defined, for example, as the dose prescribed based on regional practice or local guidelines, or the dose that is maximally tolerated due to an adverse reaction to a higher dose prescribed in the local prescribing information for pediatric patients. Statin intolerance can be defined, for example, as the inability to tolerate at least 2 statins: one statin at the lowest daily starting dose, and the other statin at any dose. Patients not receiving a daily regimen of statins (eg, 1 to 3 times per week) were also considered unable to tolerate the daily dose.

45歲、女性年齡

55歲、微量/大量白蛋白尿的病史、糖尿病視網膜病變的病史、早發性CHD的家族史(55歲的年齡以前的父親或兄弟；65歲的年齡以前的母親或姐妹)、低HDL-C(男性<40mg/dL[1.0mmol/L]，和女性<50mg/dL[1.3mmol/L])，以及記錄的慢性腎病(CKD)(例如，如實例2的納入標準中所限定的)。 In addition, patients may be selected for treatment if they have high cardiovascular (CV) risk. In certain embodiments, high CV risk patients have a documented history of cardiovascular disease (CVD) and/or at least one additional CV risk factor. CVD includes, but is not limited to, coronary heart disease (CHD) and CHD risk equivalents. CHD includes, but is not limited to, acute myocardial infarction (MI), asymptomatic MI, unstable angina, coronary revascularization procedures (eg, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG)) and clinically significant CHD (eg, diagnosed by invasive or non-invasive tests such as coronary angiography, stress testing with a treadmill, stress echocardiography, or nuclear imaging). CHD risk-equivalent conditions include, but are not limited to, peripheral arterial disease (e.g., as described in the inclusion criteria in Example 2) and previous ischemic stroke of atherothrombotic origin with focal ischemic neurological deficit. CV risk factors include but are not limited to hypertension, recent smoking, male age

45 years old, female age

55 years of age, history of micro/macroalbuminuria, history of diabetic retinopathy, family history of early-onset CHD (father or brother before age 55; mother or sister before age 65), low HDL- C (<40 mg/dL [1.0 mmol/L] for men, and <50 mg/dL [1.3 mmol/L] for women), and documented chronic kidney disease (CKD) (e.g., as defined in the inclusion criteria in Example 2) .

In certain embodiments, the high CV risk patient has atherosclerotic cardiovascular disease (ASCVD). In certain embodiments, ASCVD is defined as coronary heart disease (CHD), ischemic stroke, or peripheral artery disease. In certain embodiments, CHD includes acute myocardial infarction, asymptomatic myocardial infarction, and unstable angina. In certain embodiments, CHD is defined as acute myocardial infarction, asymptomatic myocardial infarction, or unstable angina.

insulin therapy

As shown herein, diabetic patients selected for treatment by the methods of the present invention have received and continue to receive insulin therapy comprising insulin or a derivative thereof. Insulins on the market differ in the origin of the insulin (eg bovine, porcine, human insulin) and also in their composition, which can influence the characteristics of action (onset of action and duration of action). By combining different insulin products it is possible to obtain multiple action profiles and establish blood glucose levels as close as possible to physiologic. Exemplary insulin therapy may include naturally occurring insulins, such as human insulin, and modified insulins with prolonged duration of action, such as insulin glargine (Gly(A21)-Arg(B31)-Arg(B32) human insulin, For example, ^Lantus® ). Insulin glargine is injected as an acidic clear solution and, due to its solution properties in the physiological pH range of the subcutaneous tissue, precipitates as a stable hexameric association. Insulin glargine is injected once daily and is notable for its flat serum profile and corresponding reduction in the risk of nocturnal hypoglycemia over other long-acting insulins (Schubert-Zsilavecz et al., 2:125-130 (2001)) . Insulin glargine may be administered at concentrations above 100 U/mL, for example, 270-330 U/mL insulin glargine or 300 U/mL insulin glargine (as disclosed in EP 2387989), other exemplary insulin treatments include: Insulin lisine (eg, Apidra ^® ), insulin detemir (eg, Levemir ^® ), insulin lispro (eg, Humalog ^® , Liprolog ^® ), insulin degludec (eg, DegludecPlus ^® , IdegLira (NN9068)), insulin aspart, and aspart preparations (e.g. NovoLog ^® ), basal insulins and analogs (e.g. LY2605541, LY2963016, NN1436), pegylated insulin lispro (e.g. LY-275585), long-acting insulins (e.g. NN1436, Insumera (PE0139), AB-101, AB-102, Sensulin LLC), intermediate-acting insulins (eg, Humulin ^® N, Novolin ^® N), rapid- and short-acting insulins (eg, Humulin ^® R, Novolin ^® R, Linjeta ^® (VIAject ^® ), PH20 insulin, NN1218, HinsBet ^® ), premixed insulin, SuliXen ^® , NN1045, insulin plus Symlin ^® , PE-0139, ACP-002 hydrogel insulin, and oral, inhalable, transdermal, and oral or sublingual insulins (eg Exubera ^® , Nasulin ^® , Afrezza ^® , insulin tregopil, TPM-02 insulin, Capsulin ^® , Oral-lyn ^® , Cobalamin ^® oral insulin, ORMD-0801, Oshadi oral insulin, NN1953, NN1954, NN1956, VIAtab ^® ). Also suitable are those insulin derivatives that are bound to albumin or another protein via a bifunctional linker.

PCSK9 inhibitors

The method comprises administering to a patient a therapeutic composition comprising a PCSK9 inhibitor. As used herein, a "PCSK9 inhibitor" is any agent that binds or interacts with human PCSK9 and inhibits the normal biological function of PCSK9 in vitro or in vivo. Non-limiting examples of classes of PCSK9 inhibitors include small molecule PCSK9 antagonists, nucleic acid-based inhibitors of PCSK9 expression or activity (e.g., siRNA or antisense), peptide-based molecules that specifically interact with PCSK9 (e.g., peptide peptibody), receptor molecules that specifically interact with PCSK9, proteins that comprise the ligand-binding portion of the LDL receptor, PCSK9-binding scaffold molecules (e.g., DARPins, HEAT repeat proteins, ARM repeat proteins, triangular tetrapeptide repeats protein (tetratricopeptide repeat protein), fibronectin-based scaffold constructs and other scaffolds based on naturally occurring repeat proteins, etc.), [see, for example, Boersma and Pluckthun, 2011, Curr.Opin.Biotechnol.22 :849-857 , and references cited therein], and anti-PCSK9 aptamers or portions thereof. According to certain embodiments, a PCSK9 inhibitor that may be used in the context of the methods of the invention is an anti-PCSK9 antibody or an antigen-binding fragment of an antibody that specifically binds human PCSK9.

As used herein, the term "human proprotein convertase subtilisin/kexin type 9" or "human PCSK9" or "hPCSK9" refers to a nucleotide sequence having the nucleic acid sequence shown in SEQ ID NO: 197 and SEQ ID NO: 198 The amino acid sequence of PCSK9, or a biologically active fragment thereof.

As used herein, the term "antibody" is intended to refer to immunoglobulin molecules comprising four polypeptide chains (two heavy (H) chains and two light (L) chains interconnected by disulfide bonds), as well as their body (eg, IgM). Each heavy chain is comprised of a heavy chain variable region (abbreviated herein as HCVR or _VH ) and a heavy chain constant region. The heavy chain constant region comprises three domains, _CH1 , _CH2 and _CH3 . Each light chain is comprised of a light chain variable region (abbreviated herein as LCVR or V _L ) and a light chain constant region. The light chain constant region comprises one domain ( _CL1 ). The _VH and _VL regions can be further subdivided into hypervariable regions called complementarity determining regions (CDRs), interspersed with more conserved regions called framework regions (FRs). Each _VH and _VL consists of three CDRs and four FRs, arranged from amino-terminus to carboxy-terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In various embodiments, the FRs of the anti-PCSK9 antibody (or antigen-binding portion thereof) may be identical to human germline sequences, or may be natural or artificially modified. Amino acid consensus sequences can be defined based on parallel analysis of two or more CDRs.

As used herein, the term "antibody" also includes antigen-binding fragments of intact antibody molecules. As used herein, the terms "antigen-binding portion" of an antibody, "antigen-binding fragment" of an antibody, and the like include any naturally occurring, enzymatically obtainable, synthetic or genetically engineered compound that specifically binds an antigen to form a complex. polypeptide or glycoprotein. Antigen-binding fragments of antibodies can be derived, for example, from intact antibody molecules using any suitable standard technique, such as proteolytic digestion or recombinant genetic engineering techniques involving manipulation and expression of DNA encoding antibody variable and optionally constant domains. Such DNA is known and/or readily obtainable, eg, from commercial sources, DNA libraries (including, eg, phage-antibody libraries), or may be synthesized. DNA can be sequenced and chemically manipulated or manipulated using molecular biology techniques, for example, to arrange one or more variable and/or constant domains into a suitable configuration, or to introduce codons, produce cysteamine acid residues, modification, addition or deletion of amino acids, etc.

Non-limiting examples of antigen-binding fragments include: (i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single chain Fv (scFv) molecules; (vi) dAb fragments; and (vii) A minimal recognition unit consisting of amino acid residues mimicking a hypervariable region of an antibody (eg, an isolated complementarity determining region (CDR), such as a CDR3 peptide), or a constrained FR3-CDR3-FR4 peptide. Other engineered molecules such as domain-specific antibodies, single-domain antibodies, domain-deleted antibodies, chimeric antibodies, CDR-grafted antibodies, diabodies, triabodies, tetrabodies, minibodies, nanobodies (e.g., monovalent nanobodies Antibodies, bivalent Nanobodies, etc.), small modular immunopharmaceuticals (SMIPs) and shark variable IgNAR domains are also included within the expression "antigen-binding fragment" as used herein.

Antigen-binding fragments of antibodies will generally comprise at least one variable domain. A variable domain can be of any size or amino acid composition, and will generally comprise at least one CDR adjacent to or in frame with one or more framework sequences. In an antigen-binding fragment having a _VH domain linked to a _VL domain, the _VH and _VL domains may be placed in any suitable arrangement relative to each other. For example, the variable region _{may be dimeric and contain a VH-VH , VH} - _VL or _VL - _VL dimer. Alternatively, antigen-binding fragments of antibodies may contain monomeric _VH or _VL domains.

In certain embodiments, an antigen-binding fragment of an antibody may contain at least one variable domain covalently linked to at least one constant domain. Non-limiting exemplary structures of variable and constant domains that can be found in antigen-binding fragments of antibodies include: (i) _VH - _CH1 ; (ii) _VH - _CH2 ; (iii) _{VH -CH3} ; (iv) _VH - _CH1 -CH2; (v) _VH - _CH1 - _CH2 -CH3; ₍ vi) _VH - _{CH2 - CH3} (vii) V _H -C _L ; (viii) V _{L -CH} 1 ; (ix) V _{L -CH} 2 ; (x) V _{L -CH} 3 ; (xi) V _L -CH ₁ - _CH2 ; (xii) VL- _CH1 - _CH2 - _{CH3 ;} (xiii) _VL - _CH2 - _CH3 ; and (xiv) _VL - _CL . In any configuration of the variable and constant domains, including any of the exemplary configurations shown above, the variable and constant domains may be directly connected to each other or may be connected by a complete or partial hinge or linker region. The hinge region can consist of at least 2 (e.g., 5, 10, 15, 20, 40, 60 or more) amino acids, which result in gaps between adjacent variable and/or constant domains in a single polypeptide molecule. Flexible or semi-flexible connections. In addition, antigen-binding fragments of antibodies may comprise any of the variable and constant variables shown above non-covalently linked to each other and/or to one or more monomeric _VH or _VL domains (e.g., via disulfide bonds). A homodimer or heterodimer (or other multimer) of domains.

As with intact antibody molecules, antigen-binding fragments can be monospecific or multispecific (eg, bispecific). A multispecific antigen-binding fragment of an antibody will typically comprise at least two distinct variable domains, each of which is capable of specifically binding a separate antigen or different epitopes on the same antigen. Any multispecific antibody format, including the exemplary bispecific antibody formats disclosed herein, can be adapted to the context of an antigen-binding fragment of an antibody in the methods of the invention using routine techniques available in the art.

The constant regions of antibodies are important in the ability of antibodies to fix complement and mediate cell-dependent cytotoxicity. Thus, the isotype of the antibody can be selected based on whether it is desired for the antibody to mediate cytotoxicity.

As used herein, the term "human antibody" is intended to include antibodies having variable and constant regions derived from human germline immunoglobulin sequences. Human antibodies may, however, comprise amino acid residues not encoded by human germline immunoglobulin sequences (e.g., mutations introduced by random or site-specific mutagenesis in vitro or by somatic mutation in vivo), e.g., in the CDRs , especially in CDR3. However, as used herein, the term "human antibody" is not intended to include antibodies in which CDR sequences derived from the germline of another mammalian species (eg, mouse) have been grafted onto human framework sequences.

As used herein, the term "recombinant human antibody" is intended to include all human antibodies prepared, expressed, produced or isolated by recombinant means, such as antibodies expressed using recombinant expression vectors transfected into host cells (further described below) , antibodies isolated from recombinants, combinatorial human antibody libraries (described further below), antibodies isolated from animals (e.g., mice) transgenic for human immunoglobulin genes, (see, e.g., Taylor et al. (1992 ) Nucl. Acids Res. 20:6287-6295) or antibodies prepared, expressed, produced or isolated by any other means involving splicing of human immunoglobulin gene sequences to other DNA sequences. Such recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences. However, in certain embodiments, such recombinant human antibodies undergo in vitro mutagenesis (or, when using animals transgenic for human Ig sequences, in vivo somatic mutagenesis), and thus the _VH and _VL of the recombinant antibody The amino acid sequence of a region is one that, when derived from and related to human germline _VH and _VL sequences, may not naturally occur in vivo in the human antibody germline repertoire.

Human antibodies can exist in two forms that are associated with hinge heterogeneity. In one form, the immunoglobulin molecule comprises a stable four-chain construct of approximately 150-160 kDa in which the dimers are held together by interchain heavy chain disulfide bonds. In the second form, the dimer does not pass through the interchain two Sulfur bonds and form molecules of approximately 75-80 kDa consisting of covalently coupled light and heavy chains (half antibodies). These forms are extremely difficult to isolate, even after affinity purification.

The frequency with which the second form occurs among the various intact IgG isotypes is due to, but not limited to, structural differences associated with the antibody's hinge region isotypes. A single amino acid substitution in the hinge region of the human IgG4 hinge can significantly reduce the appearance of the second form (Angal et al. (1993) Molecular Immunology 30:105) to levels commonly observed with human IgG1 hinges. The methods of the invention include antibodies with one or more mutations in the hinge, _CH2 or _CH3 regions, which may be desirable, for example, in production to improve the yield of the desired antibody form.

As used herein, "isolated antibody" means an antibody that has been identified and separated and/or recovered from at least one component of its natural environment. For example, an antibody that has been isolated or removed from at least one component of an organism or from a tissue or cell in which it is naturally present or produced is an "isolated antibody" for the purposes of the methods of the invention. Isolated antibody also includes antibody in situ within recombinant cells. Isolated antibody is one that has been subjected to at least one purification or isolation step. According to certain embodiments, an isolated antibody may be substantially free of other cellular material and/or chemicals.

The terms "specifically bind" and the like mean that an antibody or antigen-binding fragment thereof forms a complex with an antigen that is relatively stable under physiological conditions. Methods for determining whether an antibody specifically binds an antigen are well known in the art and include, for example, equilibrium dialysis, surface plasmon resonance, and the like. For example, an antibody that "specifically binds" PCSK9 as used in the context of the present methods includes antibodies that bind PCSK9 or a portion thereof with a _KD of less than about 1000 nM, less than about 500 nM, less than about 300 nM, less than about 200 nM, less than about 100 nM , less than about 90 nM, less than about 80 nM, less than about 70 nM, less than about 60 nM, less than about 50 nM, less than about 40 nM, less than about 30 nM, less than about 20 nM, less than about 10 nM, less than about 5 nM, less than about 4 nM, less than about 3 nM, less than About 2 nM, less than about 1 nM or less than about 0.5 nM as measured in a surface plasmon resonance assay. However, isolated antibodies that specifically bind human PCSK9 are cross-reactive with other antigens, such as PCSK9 molecules from other (non-human) species.

Anti-PCSK9 antibodies useful in the present methods may comprise one or more amino acids in the framework and/or CDR regions of the heavy and light chain variable domains compared to the corresponding germline sequences from which the antibodies were derived Substitutions, insertions and/or deletions. Such mutations can readily be determined by comparing the amino acid sequences disclosed herein to germline sequences available, for example, from public antibody sequence databases. The method includes the use of antibodies and antigen-binding fragments thereof derived from any of the amino acid sequences disclosed herein, wherein one or more amino acids within one or more framework and/or CDR regions are mutated to the species from which the antibody is derived. the corresponding residues of a human germline sequence, or mutations to the corresponding residues of another human germline sequence, or mutations to conservative amino acid substitutions of the corresponding germline residues (such sequence changes are collectively referred to herein as "germline mutations") ). Starting from the heavy and light chain variable region sequences disclosed herein, one of ordinary skill in the art can readily generate a number of antibodies and antigen-binding fragments comprising one or more individual germline mutations or combinations thereof . In certain embodiments, all framework and/or CDR residues within the _VH and/or _VL domains are mutated back to residues found in the original germline sequence from which the antibody was derived. In other embodiments, only certain residues are mutated back to the original germline sequence, for example, mutated residues found only within the first 8 amino acids of FR1 or within the last 8 amino acids of FR4, or Mutated residues found only in CDR1, CDR2 or CDR3. In other embodiments, one or more framework and/or CDR residues are mutated to the corresponding residues of a different germline sequence (ie, a germline sequence different from that from which the antibody was originally derived). In addition, antibodies may contain any combination of two or more germline mutations within the framework and/or CDR regions, e.g., wherein certain individual residues are mutated to the corresponding residues of a particular germline sequence other than the original germline sequence. Certain other residues of the germline sequence were either maintained or mutated to the corresponding residues of a different germline sequence. Once obtained, antibodies and antigen-binding fragments containing one or more germline mutations can be readily tested for one or more desired properties, such as improved binding specificity, increased binding affinity, improved or enhanced antagonism or agonism Sexual biological properties (as the case may be), reduced immunogenicity, etc. The use of antibodies and antigen-binding fragments obtained in this general manner is encompassed in this method.

The method involves the use of an anti-PCSK9 antibody comprising a variant of any of the HCVR, LCVR and/or CDR amino acid sequences disclosed herein with one or more conservative substitutions. For example, the methods of the invention include the use of anti-PCSK9 antibodies having HCVR, LCVR, and/or CDR amino acid sequences that are relative to any of the HCVR, LCVR, and/or The CDR amino acid sequences have, for example, 10 or fewer, 8 or fewer, 6 or fewer, 4 or fewer, etc. conservative amino acid substitutions.

As used herein, the term "surface plasmon resonance" refers to an optical phenomenon that allows, for example, using the BIAcore ^™ system (Biacore Life Sciences division of GE Healthcare, Piscataway, NJ), the detection of proteins within a biosensor matrix (Piscataway, NJ). concentration changes to analyze real-time interactions.

As used herein, the term " _KD " is intended to refer to the equilibrium dissociation constant for a particular antibody-antigen interaction.

The term "epitope" refers to an antigenic determinant that interacts with a specific antigen-binding site in the variable region of an antibody molecule called a paratope. A single antigen may have more than one epitope. Thus, different antibodies can bind different regions on the antigen and can have different biological effects. Epitopes can be either conformational or linear. Conformational epitopes are generated by the spatial juxtaposition of amino acids from different segments of the linear polypeptide chain. A linear epitope is one that arises from adjacent amino acid residues in a polypeptide chain. In certain instances, an epitope may include a sugar, phosphonyl, or sulfonyl moiety on the antigen.

According to certain embodiments, the anti-PCSK9 antibody used in the method is an antibody with pH-dependent binding characteristics. As used herein, the expression "pH-dependent binding" means that the antibody or antigen-binding fragment thereof exhibits "decreased binding to PCSK9 at acidic pH compared to neutral pH" (for the purposes of this disclosure, interchangeably use both expressions). For example, an "antibody having pH-dependent binding characteristics" includes antibodies and antigen-binding fragments thereof that bind PCSK9 with higher affinity at neutral pH than at acidic pH. In certain embodiments, the antibodies and antigen-binding fragments bind PCSK9 with an affinity at least 3, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50 higher at neutral pH than at acidic pH , 55, 60, 65, 70, 75, 80, 85, 90, 95, 100 or more times.

According to this aspect, an anti-PCSK9 antibody having pH-dependent binding characteristics may have one or more amino acid variations relative to the parental anti-PCSK9 antibody. For example, an anti-PCSK9 antibody having pH-dependent binding characteristics may contain one or more histidine substitutions or insertions, eg, in one or more CDRs of a parental anti-PCSK9 antibody. Thus, according to certain embodiments, there are provided methods comprising administering an anti-PCSK9 antibody which, in addition to substituting a histidine residue for one or more amino acids of one or more CDRs of the parental antibody, Comprising CDR amino acid sequences (eg, heavy and light chain CDRs) identical to those of the parental anti-PCSK9 antibody. Anti-PCSK9 antibodies with pH-dependent binding can have, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9 or more histidine substitutions, either within a single CDR of the parent antibody or spread in pro Within multiple (eg, 2, 3, 4, 5 or 6) CDRs of the present anti-PCSK9 antibodies. For example, the methods of the invention include the use of an anti-PCSK9 antibody with pH-dependent binding comprising one or more histidine substitutions in HCDR1, one or more histidine substitutions in HCDR2, One or more histidine substitutions in HCDR3, one or more histidine substitutions in LCDR1, one or more histidine substitutions in LCDR2, and/or one or more histidine substitutions in LCDR3 .

As used herein, the expression "acidic pH" means a pH of 6.0 or lower (eg, less than about 6.0, less than about 5.5, less than about 5.0, etc.). The expression "acidic pH" includes about 6.0, 5.95, 5.90, 5.85, 5.8, 5.75, 5.7, 5.65, 5.6, 5.55, 5.5, 5.45, 5.4, 5.35, 5.3, 5.25, 5.2, 5.15, 5.1, 5.05, 5.0 or more small pH. As used herein, the expression "neutral pH" refers to a pH of about 7.0 to about 7.4. The expression "neutral pH" includes pHs of about 7.0, 7.05, 7.1, 7.15, 7.2, 7.25, 7.3, 7.35 and 7.4.

Non-limiting examples of anti-PCSK9 antibodies that can be used in the context of the methods of the invention include, for example, alirocumab, evoclizumab, bococizumab, rodixizumab, ralpancizumab, LY3015014, or an antigen-binding portion of any of the foregoing antibodies.

Production of Human Antibodies

Methods for generating human antibodies in transgenic mice are known in the art. Any such known method may be used in the context of the methods of the present invention to produce human antibodies that specifically bind human PCSK9.

Using VELOCIMMUNE ^™ technology (see, e.g., US 6,596,541, Regeneron Pharmaceuticals) or any other known method for generating monoclonal antibodies, a high-affinity chimeric PCSK9 with human variable regions and mouse constant regions was initially isolated. Antibody. VELOCIMMUNE® technology involves the generation of transgenic mice with genomes of human heavy and light chain variable regions operably linked to endogenous mouse constant region loci such that the mice respond to antigenic stimulation to produce Antibodies for variable and mouse constant regions. DNA encoding the variable regions of the heavy and light chains of the antibody is isolated and operably linked to DNA encoding the constant regions of the human heavy and light chains. The DNA is then expressed in cells capable of expressing fully human antibodies.

Typically, VELOCIMMUNE® mice are challenged with the antigen of interest, and lymphocytes (such as B cells) are recovered from antibody-expressing mice. Lymphocytes can be fused with myeloma cell lines to produce immortal hybridoma cell lines, and such hybridoma cell lines screened and selected to identify hybridoma cell lines that produce antibodies specific for an antigen of interest. DNA encoding the variable regions of the heavy and light chains can be isolated and ligated to the desired isotype constant regions of the heavy and light chains. Such antibody proteins can be produced in cells such as CHO cells. Alternatively, DNA encoding antigen-specific chimeric antibodies or light and heavy chain variable domains can be isolated directly from antigen-specific lymphocytes.

Initially, high affinity chimeric antibodies were isolated with human variable regions and mouse constant regions. Antibodies are characterized and selected for desired characteristics, including affinity, selectivity, epitope, etc., using standard methods known to those skilled in the art. The mouse constant regions are replaced with the desired human constant regions to generate fully human antibodies, such as wild-type or modified IgGl or IgG4. While the constant region chosen will vary according to the particular application, the high affinity antigen-binding and target-specific features are present in the variable region.

In general, antibodies that can be used have high affinity as measured by binding to the antigen immobilized on a solid phase or in solution phase, as described above. The mouse constant regions are replaced with the desired human constant regions to generate fully human antibodies. While the constant region chosen will vary according to the particular application, the high affinity antigen-binding and target-specific features are present in the variable region.

Specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind PCSK9 that can be used in the context of this method include any antibody or antigen-binding fragment comprising three heavy chain CDRs (HCDR1, HCDR2, and HCDR3) that The chain CDRs are contained in, or at least 90%, at least 95%, at least 98% identical to, a heavy chain variable region (HCVR) having an amino acid sequence selected from the group consisting of SEQ ID NO: 1 and 11 or contained in substantially similar sequences with at least 99% sequence identity. Alternatively, specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind PCSK9 that may be used in the context of the methods of the invention include any antibody or antigen-binding fragment comprising the three heavy chain CDRs (HCDR1, HCDR2 and HCDR3), The three heavy chain CDRs are contained in a heavy chain variable region (HCVR) having an amino acid sequence selected from the group consisting of: SEQ ID NO 37, 45, 53, 61, 69, 77, 85 , 93, 101, 109, 117, 125, 133, 141, 149, 157, 165, 173, 181 and 189, or Contained in substantially similar sequences having at least 90%, at least 95%, at least 98%, or at least 99% sequence identity. The antibody or antigen-binding fragment may comprise three light chain CDRs (LCVR1, LCVR2, LCVR3) that are variable in the light chain having an amino acid sequence selected from the group consisting of SEQ ID NOs 6 and 15. region (LCVR), or is contained in a substantially similar sequence having at least 90%, at least 95%, at least 98%, or at least 99% sequence identity thereto. Alternatively, the antibody or antigen-binding fragment may comprise three light chain CDRs (LCVR1, LCVR2, LCVR3) in a light chain variable region having an amino acid sequence selected from the group consisting of Contains: SEQ ID NO 41, 49, 57, 65, 73, 81, 89, 97, 105, 113, 121, 129, 137, 145, 153, 161, 169, 177, 185 and 193, or in combination with Contained in substantially similar sequences having at least 90%, at least 95%, at least 98%, or at least 99% sequence identity.

Using optimal sequence alignment over the entire length of the reference amino acid sequence (i.e. the amino acid sequence identified by the SEQ ID NO) and/or over the region of optimal sequence alignment between the two amino acid sequences , to determine the sequence identity between two amino acid sequences, where optimal sequence alignment can be achieved with tools known in the art (e.g., Align), using standard settings, preferably EMBOSS::needle, Matrix:Blosum62 , Gap Open 10.0, Gap Extend 0.5 obtained.

In certain embodiments, the antibody or antigen binding protein comprises a pair of heavy and light chain variable region amino acid sequences (HCVR/LCVR) selected from the group consisting of SEQ ID NO: 1/6 and 11/15 Six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2 and LCDR3). Alternatively, in certain embodiments, the antibody or antigen binding protein comprises six CDRs (HCDR1, HCDR2) from a heavy and light chain variable region amino acid sequence pair (HCVR/LCVR) selected from the group consisting of , HCDR3, LCDR1, LCDR2 and LCDR3): SEQ ID NO: 37/41, 45/49, 53/57, 61/65, 69/73, 77/81, 85/89, 93/97, 101/105, 109/113, 117/121, 125/129, 133/137, 141/145, 149/153, 157/161, 165/169, 173/177, 181/185 and 189/193.

In certain embodiments, the anti-PCSK9 antibody or antigen-binding protein useful in the method has a protein selected from the group consisting of SEQ ID NO: 2/3/4/7/8/10 (mAb316P [also known as "REGN727" or "Ariku monoclonal antibody”]) and 12/13/14/16/17/18 (mAb300N) (see US Patent Application Publication No. 2010/0166768) and 12/13/14/16/17/18 HCDR1/HCDR2/HCDR3/LCDR1/LCDR2/LCDR3 amino acid sequence, wherein SEQ ID NO: 16 comprises a substitution of histidine for leucine at amino acid residue 30 (L30H).

In certain embodiments, the antibody or antigen binding protein comprises an HCVR/LCVR amino acid sequence pair selected from the group consisting of SEQ ID NO: 1/6 and 11/15. In certain exemplary embodiments, the antibody or antigen binding protein comprises the HCVR amino acid sequence of SEQ ID NO:1 and the LCVR amino acid sequence of SEQ ID NO:6. In certain exemplary embodiments, the antibody or antigen binding protein comprises the HCVR amino acid sequence of SEQ ID NO:11 and the LCVR amino acid sequence of SEQ ID NO:15. In certain exemplary embodiments, the antibody or antigen binding protein comprises the HCVR amino acid sequence of SEQ ID NO: 11 and the LCVR amino acid sequence of SEQ ID NO: 15 comprising the amino acid residues Histidine at base 30 replaces leucine (L30H).

Pharmaceutical compositions and methods of administration

The method comprises administering to a patient a PCSK9 inhibitor, wherein the PCSK9 inhibitor is comprised in a pharmaceutical composition. Pharmaceutical compositions are formulated with suitable carriers, excipients and other agents to provide suitable transfer, delivery, tolerance and the like. Many suitable formulations can be found in formulations known to all medicinal chemists: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. These formulations include, for example, powders, pastes, ointments, gels, waxes, oils, lipids, lipids (cationic or anionic) containing vesicles (such as LIPOFECTIN ^™ ), DNA conjugates, anhydrous absorption pastes, oil-in-water and water-in-oil emulsions, emulsion carbowaxes (polyethylene glycols of various molecular weights), semisolid gels, and semisolid mixtures containing carbowaxes. See also Powell et al. "Compendium of excipients for parenteral formulations" PDA (1998) J Pharm Sci Technol 52:238-311.

Exemplary pharmaceutical formulations comprising anti-PCSK9 antibodies that may be used in the context of the methods of the invention include US 8,795,669 (especially describing exemplary formulations comprising alirixumab) or any of the formulations described in WO2013/166448 or WO2012/168491 .

Various delivery systems are known and can be used to administer pharmaceutical compositions, e.g. encapsulated in liposomes, microparticles, microcapsules, recombinant cells capable of expressing mutant viruses, receptor-mediated endocytosis (see, e.g., Wu et al., 1987, J. Biol. Chem. 262:4429-4432). Methods of administration include, but are not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural, and Oral route. Compositions may be administered by any convenient route, such as by infusion or bolus injection, absorbed through epithelial or mucocutaneous linings (eg oral mucosa, rectal and intestinal mucosa, etc.), and may be administered with other biologically active agents.

The pharmaceutical composition can be delivered subcutaneously or intravenously with a standard needle and syringe. Additionally, with respect to subcutaneous delivery, pen delivery devices are readily applicable for delivery of pharmaceutical compositions. Such pen delivery devices may be reusable or disposable. Reusable pen delivery devices typically utilize a replaceable cartridge containing the pharmaceutical composition. Once all of the pharmaceutical composition in the cartridge has been administered and the cartridge is empty, the empty cartridge can be easily discarded and replaced with a new cartridge containing the pharmaceutical composition. The pen delivery device can then be reused. In a disposable pen delivery device, there is no replaceable refill. In contrast, disposable pen delivery devices are prefilled with a pharmaceutical composition held in a reservoir within the device. Once the reservoir is emptied of pharmaceutical composition, the entire device is discarded.

Many reusable pen and auto-injector delivery devices have applications for the subcutaneous delivery of pharmaceutical compositions. Examples include, but are not limited to, AUTOPEN ^™ (Owen Mumford, Inc., Woodstock, UK), DISETRONIC ^™ pens (Disetronic Medical Systems, Bergdorf, Switzerland), HUMALOG MIX 75/25 ^™ pens, HUMALOG ^™ pens, HUMALIN 70/30 ^™ pens (Eli Lilly and Co., Indianapolis, IN), NOVOPEN ^TM I, II and III (Novo Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR ^TM (Novo Nordisk, Copenhagen, Denmark), BD ^TM pen (Becton Dickinson, Franklin Lakes, NJ), OPTIPEN ^™ , OPTIPEN PRO ^™ , OPTIPEN STARLET ^™ and OPTICLIK ^™ (sanofi-aventis, Frankfurt, Germany), to name a few. Examples of disposable pen delivery devices with application for subcutaneous delivery of pharmaceutical compositions of the methods of the invention include, but are not limited to, SOLOSTAR ^™ pen (sanofi-aventis), FLEXPEN ^™ (Novo Nordisk) and KWIKPEN ^™ (Eli Lilly), SURECLICK ^™ Autoinjector (Amgen, Thousand Oaks, CA), PENLET ^™ (Haselmeier, Stuttgart, Germany), EPIPEN (Dey, LP) and HUMIRA ^™ pen (Abbott Labs, Abbott Park IL), to name a few.

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

Injectable preparations may include dosage forms for intravenous, subcutaneous, intradermal and intramuscular injection, drip infusion and the like. These injectable preparations can be prepared by known methods. For example, injectable preparations can be prepared, for example, by dissolving, suspending or emulsifying the above-mentioned antibodies or salts thereof in sterile aqueous media or oily media conventionally used for injection. As the aqueous medium for injection, there are, for example, physiological saline, isotonic solutions containing glucose and other auxiliary agents, etc., which can be mixed with appropriate solubilizers (such as alcohols (for example, ethanol), polyols (for example, propylene glycol, polyethylene glycol), etc. alcohol), nonionic surfactants [for example, polysorbate 80, HCO-50 (polyoxyethylene (50 mol) addition compound of hydrogenated castor oil)], etc.). As the oily medium, for example, sesame oil, soybean oil and the like are used, which may be used in combination with a solubilizer such as benzyl benzoate, benzyl alcohol and the like. The injections thus prepared are preferably filled in appropriate ampoules.

Advantageously, the aforementioned pharmaceutical compositions for oral or parenteral use are prepared in dosage unit dosage form suitable for formulating a dose of the active ingredient. Such unit dosage forms include, for example, tablets, pills, capsules, injections (ampoules), suppositories, and the like.

dose

The amount of PCSK9 inhibitor (eg, anti-PCSK9 antibody) administered to a patient is typically a therapeutically effective amount. As used herein, the phrase "therapeutically effective amount" means a dose of a PCSK9 inhibitor that results in a detectable decrease in one or more parameters selected from the group consisting of at least about 5% from baseline, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75% or more): LDL-C, ApoB, ApoB100, non-HDL-C, total cholesterol, VLDL-C, triglycerides, ApoC3, TRL particles, Lp(a), and residual cholesterol.

In the case of an anti-PCSK9 antibody, the therapeutically effective amount may be from about 0.05 mg to about 600 mg, e.g., about 0.05 mg, about 0.1 mg, about 1.0 mg, about 1.5 mg, about 2.0 mg, about 10 mg, about 20 mg, about 30 mg , about 40mg, about 50mg, about 60mg, about 70mg, about 75mg, about 80mg, about 90mg, about 100mg, about 110mg, about 120mg mg, about 130mg, About 140mg, about 160mg, about 170mg, about 180mg, about 190mg, about 200mg, about 210mg, about 220mg, about 230mg, about 240mg, about 250mg, about 260mg, about 270mg, about 280mg, about 290mg, about 300mg, about 310mg , about 320mg, about 330mg, about 340mg, about 350mg, about 360mg, about 370mg, about 380mg mg, about 390mg, about 400mg, about 410mg, about 420mg, about 430mg, about 440mg, about 450mg, about 460mg, about 470mg, About 480 mg, about 490 mg, about 500 mg, about 510 mg, about 520 mg, about 530 mg, about 540 mg, about 550 mg, about 560 mg, about 570 mg, about 580 mg, about 590 mg, or about 600 mg of the anti-PCSK9 antibody. According to certain exemplary embodiments, the therapeutically effective amount of anti-PCSK9 antibody is 30 mg, 40 mg or 75 mg (for example, in the case of alirocumab for patients weighing less than 50 kg, and/or less than or equal to 17 years old), 50 mg, 75 mg, or 150 mg (e.g., in the case of alirocumab for patients weighing greater than or equal to 50 kg, and/or ≤17 years of age), or 140 mg or 420 mg (e.g., in the case of evolocumab Down). Other dosages of PCSK9 inhibitors will be apparent to those of ordinary skill in the art.

The amount of anti-PCSK9 antibody contained in a single dose can be expressed in milligrams of antibody per kilogram of patient body weight (ie, mg/kg). For example, an anti-PCSK9 antibody can be administered to a patient at a dose of about 0.0001 to about 10 mg/kg body weight.

Application plan

According to certain embodiments, multiple doses of a PCSK9 inhibitor (i.e., a pharmaceutical composition comprising a PCSK9 inhibitor) may be administered to a subject over a defined period of time (e.g., in addition to a daily therapeutic statin regimen or other setting outside the LMT). The method according to this aspect comprises sequentially administering to the subject multiple doses of a PCSK9 inhibitor. As used herein, "sequential administration" means that each dose of the PCSK9 inhibitor is given to the subject at different time points, for example, on different days separated by predetermined intervals (for example, hours, days, weeks or months). The tester administered. The method comprises sequentially administering to the patient a single initial dose of a PCSK9 inhibitor, followed by one or more second doses of a PCSK9 inhibitor, and optionally followed by one or more third doses of a PCSK9 inhibitor.

The terms "initial dose", "second dose" and "third dose" refer to the temporal sequence of administration of the respective doses of the pharmaceutical composition comprising a PCSK9 inhibitor. Thus, the "initial dose" is the dose administered at the beginning of the treatment regimen (also referred to as the "baseline dose"); the "second dose" is the dose administered after the initial dose. The dose used; a "second dose" is a dose administered after the second dose. The initial, second and third doses may all contain the same amount of PCSK9 inhibitor, but generally may differ from each other in frequency of administration. However, in certain embodiments, the amount of PCSK9 inhibitor contained in the initial, second, and/or third doses differs from one another (eg, adjusted up or down, as appropriate) over the course of treatment. In certain embodiments, two or more (eg, 2, 3, 4, or 5) doses are administered as a "loading dose" at the beginning of a treatment regimen, followed by subsequent doses administered on a less frequent basis. Dose (eg, "maintenance dose").

According to an exemplary embodiment, each second and/or third dose is immediately followed by 1 to 26 (e.g., 1, 1½, 2, 2½, 3, 3½, 4, 4½, 5, 5½, 6, 6½, 7, 7½, 8, 8½, 9, 9½, 10, 10½, 11, 11½, 12, 12½, 13, 13½, 14, 14½, 15, 15½, 16, 16½, 17, 17½, 18, 18½, 19, 19½, 20, 20½, 21, 21½, 22, 22½, 23, 23½, 24, 24½, 25, 25½, 26, 26½ or more) weekly. As used herein, the phrase "immediately preceding dose" means, in a sequence of multiple administrations, the antigen-binding dose administered to the patient immediately prior to the administration of the next dose in the sequence without an intervening dose. The dose of the molecule.

The method according to this aspect may comprise administering to the patient any number of second and/or third doses of the PCSK9 inhibitor. For example, in certain embodiments, only a single second dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8 or more) second doses are administered to the patient. Likewise, in certain embodiments, only a single third dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8 or more) third doses are administered to the patient.

In embodiments involving multiple third doses, each second dose may be administered with the same frequency as the other second doses. For example, each second dose may be administered to the patient 1 to 2, 4, 6, 8 or more weeks after the immediately preceding dose. Similarly, in embodiments involving multiple third doses, each third dose may be administered with the same frequency as the other third doses. For example, each third dose may be administered to the patient 1 to 2, 4, 6, 8 or more weeks after the immediately preceding dose. Alternatively, the third and/or frequency of the third dose administered to the patient may vary over the course of the treatment regimen. The frequency of administration can also be adjusted during treatment by the physician according to the individual patient's needs after clinical examination.

The methods of the invention include administration regimens that include an up-titrate option (also referred to herein as "dose modification"). As used herein, an "up-titration option" means that after receiving a specified number of doses of a PCSK9 inhibitor, the dose of the PCSK9 inhibitor is thereafter increased if the patient has not achieved a specified reduction in one or more defined treatment parameters. For example, in the case of a treatment regimen that includes administering a 75 mg dose of an anti-PCSK9 antibody to a patient at a biweekly frequency, if after 8 weeks (i.e., at week 0, week 2, week 4, week 6 weeks and 8 weeks), the patient has not yet achieved a serum LDL-C concentration of less than 70 mg/dL, and thereafter the dose of anti-PCSK9 antibody is increased to, for example, 150 mg every two weeks (e.g., from week 10 or week 12 or later).

70mg/dL，則停止約75mg劑量，並且隨後以約150mg的劑量以每兩週一次的頻率向患者施用特異性結合PCSK9的該抗體或其抗原結合片段。 In certain embodiments, the antibody or antigen-binding fragment thereof that specifically binds PCSK9 is administered to the patient at a dose of about 75 mg every two weeks. In certain embodiments, if the patient's LDL-C measured after one or more, two or more, three or more, four or more or five or more doses <70mg/dL, then maintain a dose of about 75mg. In certain embodiments, if the patient's LDL measured after one or more, two or more, three or more, four or more, or five or more doses- C still

70 mg/dL, the about 75 mg dose is discontinued, and the antibody or antigen-binding fragment thereof that specifically binds PCSK9 is then administered to the patient at a dose of about 150 mg every two weeks.

70mg/dL，則停止約300mg劑量，並且隨後以約150mg的劑量以每兩週一次的頻率向患者施用該特異性結合PCSK9的抗體或其抗原結合片段。 In certain embodiments, the antibody or antigen-binding fragment thereof that specifically binds PCSK9 is administered to the patient at a dose of about 300 mg once every four weeks. In certain embodiments, if the patient's LDL-C measured after one or more, two or more, three or more, four or more, or five or more doses < 70mg/dL, then maintain a dose of about 300mg. In certain embodiments, if the patient's LDL-C measured after one or more, two or more, three or more, four or more or five or more doses remains

70 mg/dL, the about 300 mg dose is discontinued, and the antibody or antigen-binding fragment thereof that specifically binds PCSK9 is then administered to the patient at a dose of about 150 mg every two weeks.

In certain embodiments, the antibody or antigen-binding fragment thereof that specifically binds PCSK9 is administered to the patient at a dose of about 150 mg every two weeks.

In certain embodiments, when an antibody or antigen-binding fragment thereof that specifically binds PCSK9 is administered to a patient at a dose of about 150 mg every two weeks, if at least one If the patient's LDL-C < 10, 15, 20 or 25 mg/dL is measured after three doses or at least two, three, four or five consecutive doses, the approximately 150 mg dose is discontinued, followed by approximately 75 mg per dose The antibody or antigen-binding fragment thereof that specifically binds PCSK9 is administered to the patient at a biweekly frequency. While not wishing to be bound by theory, it is hypothesized that very low LDL-C levels (eg, <10, 15, 20, or 25 mg/dL) can exacerbate diabetes. In certain embodiments, a dose of about 150 mg is administered to the patient at a constant dose. In certain embodiments, the patient is administered a dose of about 150 mg following dose adjustments as disclosed herein (eg, from about 75 mg every two weeks, or from about 300 mg every four weeks).

combination therapy

As described elsewhere herein, the method may include combining the PCSK9 inhibitor with the patient's previously prescribed lipid-modifying therapy (LMT) ("adding the PCSK9 inhibitor to the patient's previously prescribed lipid-modifying therapy (LMT)") administered to patients. LMTs include, but are not limited to, statins, fibrates, niacin (e.g., niacin and its derivatives), bile acid sequestrants, ezetimibe, lomitapide, phytosterols, Orlistat (orlistat) etc. For example, a PCSK9 inhibitor can be administered to a patient in conjunction with a stable daily therapeutic statin regimen. Exemplary daily therapeutic statin regimens that may be administered in combination with PCSK9 inhibitors in the context of the methods of the invention include, for example, atorvastatin (10, 20, 40, or 80 mg daily), (atorvastatin/et Zetimibe 10/10 or 40/10 mg per day), rosuvastatin (5, 10 or 20 mg per day), cerivastatin (0.4 or 0.8 mg per day), pitavastatin (1, 2 or 4mg), fluvastatin (20, 40, or 80mg daily), simvastatin (5, 10, 20, 40, or 80mg daily), simvastatin/ezetimibe (10/10, 20 /10, 10/10 or 80/10mg), lovastatin (10, 20, 40 or 80mg per day), pravastatin (10, 20, 40 or 80mg per day), and combinations thereof. In certain embodiments, the statin therapy is the maximally tolerated statin therapy for the patient. Other LMTs that may be administered in combination with PCSK9 inhibitors in the context of the methods of the invention include, for example, (1) agents that inhibit cholesterol uptake and/or bile acid reabsorption (e.g., ezetimibe); (2) agents that increase lipid Agents of protein catabolism (such as niacin); and/or (3) activators of LXR transcription factors that play a role in the elimination of cholesterol, such as 22-hydroxycholesterol.

According to certain embodiments, there is provided a combination of a PCSK9 inhibitor (e.g., an anti-PCSK9 antibody, such as alirixumab, evoclizumab, bococizumab, rodixizumab, ralpancizumab, or LY3015014) with angiopoietin-like protein 3 Inhibitors (for example, anti- ANGPTL3 antibodies, such as REGN1500), inhibitors of angiopoietin-like protein 4 (e.g., anti-ANGPTL4 antibodies, such as the anti-ANGPTL4 antibodies referred to as "H1H268P" or "H4H284P" in U.S. Patent No. 9,120,851), or angiopoietin-like protein 8 A method of administering a combination of inhibitors (eg, anti-ANGPTL8 antibodies) to a patient.

According to certain embodiments, there is provided a treatment comprising, in addition to insulin therapy, a PCSK9 inhibitor (e.g., an anti-PCSK9 antibody, such as alekizumab, evolocizumab, bococizumab, rhodexitizumab, ralpancizumab, or LY3015014) A method of administering to a patient in combination with an additional antidiabetic treatment. Exemplary additional antidiabetic treatments include, but are not limited to:

(a) All drugs mentioned in Rote Liste 2016, (eg all antidiabetic drugs mentioned in Chapter 12 of Rote Liste 2014), all weight loss or appetite suppressants mentioned in Chapter 06 of Rote Liste 2016, in All lipid-lowering agents mentioned in Chapter 58 of Rote Liste 2016, all antihypertensive drugs mentioned in Chapter 17 of Rote Liste 2016, all kidney-sparing drugs mentioned in Rote Liste 2016, or Chapter 36 of Rote Liste 2016 All diuretics mentioned;

(b) Glucagon-like peptide 1 (GLP-1) therapy, including GLP-1, GLP-1 analogs, and GLP-1 receptor agonists, such as: GLP-1(7-37), GLP-1 1(7-36)amide, lixisenatide (e.g. Lyxumia ^® ), exenatide (e.g. exendin-4, exendin-4, Byetta ^® , Bydureon ^® , exenatide NexP), exenatide-LAR, liraglutide (such as Victoza ^® ), semaglutide (semaglutide), taspoglutide (taspoglutide), albiglutide (albiglutide) ), dulaglutide, albumin-glucagon-like peptide-1 (albugon), oxyntomodulin, geniproside, ACP-003, CJC-1131, CJC-1134- PC, GSK-2374697, PB-1023, TTP-054, langlenatide (HM-11260C), CM-3, GLP-1 Eligen, AB-201, ORMD-0901, NN9924, NN9926, NN9927, Nodexen, Viador-GLP- 1. CVX-096, ZYOG-1, ZYD-1, ZP-3022, CAM-2036, DA-3091, DA-15864, ARI-2651, ARI-2255, Exenatide-XTEN (VRS-859), Exenatide-XTEN+Glucagon-XTEN (VRS-859+AMX-808) and polymer-conjugated GLP-1 and GLP-1 analogs;

(c) Dual GLP-1/GIP agonists (e.g. RG-7697 (MAR-701), MAR-709, BHM081, BHM089, BHM098); dual GLP-1/glucagon receptor agonists (e.g. BHM-034, OAP-189 (PF-05212389, TKS-1225), TT-401/402, ZP2929, LAPS-HMOXM25, MOD-6030);

(d) dual GLP-1/gastrin agonists (eg ZP-3022);

(e) gastrointestinal peptides, such as peptide YY 3-36 (PYY3-36) or analogs thereof and pancreatic polypeptide (PP) or analogs thereof;

(f) glucagon receptor agonists or antagonists, glucose-dependent insulinotropic polypeptide (GIP) receptor agonists or antagonists, growth hormone releasing hormone antagonists or inverse agonists, xenin and its analog;

(g) dipeptidyl peptidase-IV (DPP-4) inhibitors, for example: alogliptin (eg Nesina ^® , Kazano ^® ), linagliptin (eg Ondero ^® , Trajenta ^® , Tradjenta ® ) ^® , Trayenta ^® ), saxagliptin (eg Onglyza ^® , Komboglyze XR ^® ), sitagliptin (eg Januvia ^® , Xelevia ^® , Tesavel ^® , Janumet ^® , Velmetia ^® , Juvisync ^® , Janumet XR ® ^® ), anagliptin, teneligliptin (e.g. Tenelia ^® ), trelagliptin (trelagliptin), vildagliptin (e.g. Galvus ^® , Galvumet ^® ), gemagliptin (gemigliptin), omarigliptin, evogliptin, dutogliptin, DA-1229, MK-3102, KM-223, KRP-104, PBL-1427, hydrochloric acid Pinoxacin hydrochloride and Ari-2243;

(h) Sodium-dependent glucose transporter 2 (SGLT-2) inhibitors, for example: canagliflozin, dapagliflozin, remogliflozin, repagliflozin etabonate (remogliflozin etabonate), sergliflozin, empagliflozin, ipragliflozin, tofogliflozin, luseogliflozin, egliflozin ( ertugliflozin), EGT-0001442, LIK-066, SBM-TFC-039 and KGA-3235 (DSP-3235);

(i) dual inhibitors of SGLT-2 and SGLT-1 (eg LX-4211, LIK066);

(j) SGLT-1 inhibitors (eg LX-2761, KGA-3235) or SGLT-1 inhibitors in combination with anti-obesity drugs such as ileal bile acid transfer (IBAT) inhibitors (eg GSK-1614235 + GSK-2330672) ;

(k) biguanides (eg metformin, buformin, phenformin);

(l) Thiazolidinediones (eg pioglitazone, rosiglitazone), Glitazone analogues (eg lobeglitazone);

(m) Peroxisome proliferator-activated receptor (PPAR-) (α, γ, or α/γ) agonists or modulators (e.g., saroglitazar, (e.g. Lipaglyn ^® ), GFT- 505) or partial PPARγ agonists (eg Int-131);

(n) sulfonylureas (such as tolbutamide, glibenclamide, glimepiride, Amaryl ^® , glipizide) and meglitinides (meglidide) Nases, such as nateglinide, repaglinide, mitiglinide);

(o) alpha-glucosidase inhibitors (eg, acarbose, miglitol, voglibose);

(q) Amylin and amylin analogs (eg pramlintide, Symlin ^® );

(p) G protein-coupled receptor 119 (GPR119) agonists (eg, GSK-1292263, PSN-821, MBX-2982, APD-597, ARRY-981, ZYG-19, DS-8500, HM-47000, YH-Chem1);

(q) GPR40 agonists (eg TUG-424, P-1736, P-11187, JTT-851, GW9508, CNX-011-67, AM-1638, AM-5262);

(r) GPR120 agonists and GPR142 agonists;

(s) systemic or poorly absorbed TGR5 (GPBAR1 = G protein-coupled bile acid receptor 1) agonists (eg, INT-777, XL-475, SB756050);

(t) Immunotherapy for diabetes, for example: oral C-C chemokine receptor type 2 (CCR-2) antagonists (eg CCX-140, JNJ-41443532), interleukin 1β (IL-1β) antagonists (eg AC -201), or oral monoclonal antibodies (MoA) (eg, methalozamide, VVP808, PAZ-320, P-1736, PF-05175157, PF-04937319);

(v) Anti-inflammatory agents for the treatment of metabolic syndrome and diabetes, for example: nuclear factor kappa B inhibitors (eg Triolex ^® );

(w) Adenosine monophosphate-activated protein kinase (AMPK) stimulators, for example: Imeglimin (PXL-008), Debio-0930 (MT-63-78), R-118;

(x) Inhibitors of 11-beta-hydroxysteroid dehydrogenase 1 (11-beta-HSD-1) (eg LY2523199, BMS770767, RG-4929, BMS816336, AZD-8329, HSD-016, BI-135585);

(y) Glucokinase activators (eg PF-04991532, TTP-399 (GK1-399), GKM-001 (ADV-1002401), ARRY-403 (AMG-151), TAK-329, TMG-123, ZYGK1 );

(z) Inhibitors of diacylglycerol O-acyltransferase (DGAT) (eg, pradigastat (LCQ-908)), inhibitors of protein tyrosine phosphatase 1 (eg, trodusquemine), glucose-6-phosphatase inhibitors of fructose-1,6-bisphosphatase, inhibitors of glycogen phosphorylase, inhibitors of phosphoenolpyruvate carboxykinase, inhibitors of glycogen synthase kinase, pyruvate dehydrogenation Inhibitors of enzyme kinases;

(aa) Modulators of glucose transporter-4, somatostatin receptor 3 agonists (eg MK-4256);

(bb) One or more lipid-lowering agents are also suitable as combination partners, for example: 3-hydroxy-3-methylglutaryl-coenzyme-A-reductase (HMG-CoA-reductase) inhibitors, such as Simva Statins (eg Zocor ^® , Inegy ^® , Simcor ^® ), atorvastatin (eg Sortis ^® , Caduet ^® ), rosuvastatin (eg Crestor ® ), pravastatin (eg Lipostat ® , Selipran ^® ), fluvastatin (eg Lipostat ^® , Selipran ^® ), fluvastatin Statins (e.g. Lescol ^® ), pitavastatin (e.g. Livazo ^® , Livalo ^® ), lovastatin (e.g. Mevacor ^® , Advicor ^® ), mevastatin (e.g. Compactin ^® ), rivastatin (rivastatin), west Rivastatin (Lipobay ^® ), fibrates such as bezafibrate (eg Cedur ^® delayed), ciprofibrate (eg Hyperlipen ^® ), fenofibrate (eg Antara ^® , Lipofen ^® , Lipanthyl ^® ), gemfibrozil (eg Lopid ^® , Gevilon ^® ), etofibrate, simfibrate, ronifibrate, clinofibrate, clofibrate Amines (clofibride), niacin and its derivatives (such as niacin, including sustained-release formulations of niacin), niacin receptor 1 agonists (such as GSK-256073), PPAR-delta agonists , acetyl-coenzyme A-acetyltransferase (ACAT) inhibitors (such as avasimibe (avasimibe)), cholesterol absorption inhibitors (such as ezetimibe, Ezetrol ^® , Zetia ^® , Liptruzet ^® , Vytorin ^® , S -556971), bile acid binding substances (eg, cholestyramine, colesevelam), inhibitors of ileal bile acid transport (IBAT) (eg, GSK-2330672, LUM-002), microsomal triglycerides Ester transfer protein (MTP) inhibitors (e.g. lomitapide (AEGR-733), SLx-4090, granotapide), modulators of proprotein convertase subtilisin/kexin type 9 (PCSK9) (e.g. ali Culumab (REGN727/SAR236553), AMG-145, LGT-209, PF-04950615, MPSK3169A, LY3015014, ALD-306, ALN-PCS, BMS-962476, SPC5001, ISIS-394814, 1B20, LGT-210, 1D05 , BMS-PCSK9Rx-2, SX-PCK9, RG7652), LDL receptor upregulators, such as liver-selective thyroid hormone receptor beta agonists (such as eprotirome (KB-2115)), MB07811, sobetirome (QRX-431, VIA-3196, ZYT1), HDL-raising compounds such as: cholesteryl ester transfer protein (CETP) inhibitors (eg, anacetrapib (MK0859)), dalcetrapib , evacetrapib, JTT-302, DRL-17822, TA-8995, R-1658, LY-2484595, DS-1442), or dual CETP/PCSK9 inhibitors (e.g. K-312), ATP-binding Cassette (ABC1) modulators, lipid metabolism modulators (e.g. BMS-823778, TAP-301, DRL-21994, DRL-21995), phospholipase A2 (PLA2) inhibitors (e.g. darapladib, ^Tyrisa® , varespladib, rilapladib), ApoA-I enhancers (such as RVX-208, CER-001, MDCO-216, CSL-112), cholesterol synthesis inhibitors (such as ETC-1002 ), lipid metabolism regulators (such as BMS-823778, TAP-301, DRL-21994, DRL-21995) and omega-3 fatty acids and their derivatives (such as eicosapentaenoic acid ethyl (AMR101), Epanova ^® , AKR-063, NKPL-66, PRC-4016, CAT-2003);

(cc) bromocriptine (eg Cycloset® ^{, Parlodel®} ), phentermine and phentermine preparations or combinations (eg Adipex-P, Ionamin, ^Qsymia® ), benzphetamine (eg Didrex ^® ), diethylpropion (e.g. Tenuate ^® ), phendimetrazin (e.g. Adipost ^® , Bontril ^® ), bupropion and combinations (e.g. Zyban ^® , Wellbutrin XL ^® , Contrave ^® , Empatic ^® ), sibutramine (such as Reductil ^® , Meridia ^® ), topiramate (topiramat, such as Topamax ^® ), zonisamid (such as Zonegran ^® ), tesofensine (tesofensine), Opioid antagonists such as naltrexone (eg Naltrexin ^® , naltrexone + bupropion), cannabinoid receptor 1 (CB1) antagonists (eg TM-38837), melanin concentrating hormone (MCH-1 ) antagonists (eg BMS-830216, ALB-127158(a)), MC4 receptor agonists and partial agonists (eg AZD-2820, RM-493), neuropeptide Y5 (NPY5) or NPY2 antagonists ( eg velneperit, S-234462), NPY4 agonists (eg PP-1420), beta-3-adrenoceptor agonists, leptin or leptin mimetics, serotonin 2c Agonists of (5HT2c) receptors (eg lorcaserin, ^Belviq® ), pramlintide/metreleptin, lipase inhibitors such as cetilistat (eg Cametor ^® ), orlistat (eg Xenical ^® , Calobalin ^® ), angiogenesis inhibitors (eg ALS-L1023), betahistidin and histamine H3 antagonists (eg HPP-404), AgRP ( Agouti-related protein) inhibitors (eg, TTP-435), serotonin reuptake inhibitors such as fluoxetine (eg, Fluctine ^® ), duloxetine (eg, Cymbalta ^® ), di- or triple-monoamine uptake Inhibitors (dopamine, norepinephrine and serotonin reuptake) such as sertraline (eg Zoloft ^® ), tesofensine, methionine aminopeptidase 2 (MetAP2) inhibitors (eg beloranib) and antisense oligonucleotides produced against fibroblast growth factor receptor 4 (FGFR4) (eg ISIS-FGFR4Rx) or antiproliferative protein targeting peptide-1 (eg Adipotide ^® ); and

(dd) Nitric oxide donors, AT1 antagonists or angiotensin II (AT2) receptor antagonists such as telmisartan (eg Kinzal ^® , Micardis ^® ), candesartan (eg Atacand ^® , Blopress ^® ), valsartan (eg Diovan ^® , Co-Diovan ^® ), losartan (eg Cosaar ^® ), eprosartan (eg Teveten ^® ), irbesartan ( irbesartan (eg Aprovel ^® , CoAprovel ^® ), olmesartan (eg Votum ^® , Olmetec ^® ), tasosartan (tasosartan), azilsartan (eg Edarbi ^® ), dual angiotensin receptor Blockers (dual ARBs), angiotensin converting enzyme (ACE) inhibitors, ACE-2 activators, renin inhibitors, prorenin inhibitors, endothelin converting enzyme (ECE) inhibitors, endothelin receptors (ET1/ETA) blockers, endothelin antagonists, diuretics, aldosterone antagonists, aldosterone synthase inhibitors, alpha-blockers, alpha-2 adrenergic receptor antagonists, beta-receptor Somatoblockers, mixed alpha-/beta-blockers, calcium antagonists, calcium channel blockers (CCBs), nasal formulations of the calcium channel blocker diltiazem (e.g. CP-404 ), dual mineralocorticoids/CCBs, centrally acting antihypertensives, neutral endopeptidase inhibitors, aminopeptidase-A inhibitors, vasopeptide inhibitors, dual vasopeptide inhibitors such as neprilysin- ACE inhibitors or neprilysin-ECE inhibitors, dual-acting AT receptor-neprilysin inhibitors, dual AT1/ETA antagonists, advanced glycation end product (AGE) disruptors, recombinant renal enzymes, blood pressure Vaccines such as anti-RAAS (renin-angiotensin-aldosterone-system) vaccines, AT1- or AT2-vaccines, drugs based on hypertension pharmacogenomics, such as modulators of genetic polymorphisms with antihypertensive responses, coagulation Cell aggregation inhibitors and others; and

(ee) their suitable combination.

In certain embodiments, the additional antidiabetic treatment is GLP-1 treatment (eg, lixisenatide). In certain embodiments, GLP-1 therapy is formulated with methionine (eg, L-methionine or D-methionine). In certain embodiments, GLP-1 therapeutic formulations are free or substantially free of polysorbates (e.g., polysorbate 20, polysorbate 80), poloxamers (e.g., polo Sham 188), benzalkonium chloride, histidine, lysine and/or EDTA. In certain embodiments, GLP-1 therapeutic formulations are free or substantially free of surfactants, such as polyols (e.g., polypropylene glycol, polyethylene glycol, poloxamers, Pluronics, Tetronics), polyols Moieties and fatty acid esters and ethers, such as those of glycerol and sorbitol (eg, Span.RTM., Tween.RTM., Myrj.RTM., Brij.RTM., Cremophor.RTM). Formulations for GLP-1 therapy may contain suitable preservatives (e.g., phenol, m-cresol, benzyl alcohol, and/or parabens) and suitable tonicity adjusting agents (e.g., glycerol, dextrose, lactose, sorbitol Sugar alcohols, mannitol, glucose, NaCl, calcium or magnesium compounds such as _CaCl2 ). The concentrations of glycerol, dextrose, lactose, sorbitol, mannitol and glucose are usually in the range of 100-250 mM, and the concentration of NaCl is up to 150 mM.

In certain embodiments, the patient receives insulin therapy in combination with an additional antidiabetic therapy (eg, any preceding antidiabetic therapy that is not insulin therapy). For example, in certain embodiments, the antidiabetic treatment comprises a combination of insulin treatment (eg, insulin glargine) and GLP-1 treatment (eg, lixisenatide). These treatments may be provided alone or in a single pharmaceutical composition. For example, insulin glargine and lixisenatide can be formulated in a single pharmaceutical composition (eg, ^Soliqua® 100/33) for daily injection.

In the context of this method, one or more additional therapeutically active components, such as any of the agents listed above or derivatives thereof, may be administered before, simultaneously with, or shortly after administration of the PCSK9 inhibitor; (for the purposes of this disclosure, such The administration regimen is considered to be the administration of the PCSK9 inhibitor "in combination" with an additional therapeutically active component). The methods of the invention include pharmaceutical compositions and methods of use thereof, wherein a PCSK9 inhibitor is co-formulated with one or more additional therapeutically active ingredients as described elsewhere herein.

Administration of PCSK9 inhibitors as add-on therapy

The methods of treatment of the present invention include treating patients with hypercholesterolemia and diabetes with a PCSK9 inhibitor, such as an antibody or antigen-binding fragment thereof that specifically binds PCKS9, where the PCSK9 inhibitor can be used as a pre-existing insulin therapy for the patient and/or LMT (if where applicable), such as as add-on therapy to a patient's pre-existing daily therapeutic insulin and/or statin regimen.

For example, the method includes adding a regimen in which the PCSK9 inhibitor is administered to the same stable multiple daily insulin regimen and/or daily therapeutic statin regimen that the patient received prior to receiving the PCSK9 inhibitor (i.e., the same dose Add-on therapy administration of statins). In other embodiments, the PCSK9 inhibitor is administered as add-on therapy to a therapeutic insulin and/or statin regimen comprising more insulin and/or statin than the patient received prior to receiving the PCSK9 inhibitor. Or statin dose more or less amount of insulin and/or statin. For example, the daily dose of insulin and/or statin administered or prescribed to a patient after initiating a treatment regimen comprising a PCSK9 inhibitor administered at a specific dosing frequency and amount may be consistent with the patient's initial PCSK9 inhibitor treatment. The daily statin dose taken prior to the regimen was (a) kept constant, (b) increased, or (c) decreased (eg, up-titrate or down-titrate), depending on treatment needs of patients.

therapeutic efficacy

The method results in a reduction in serum levels of one or more lipid components selected from the group consisting of: LDL-C, ApoB, ApoB100, non-HDL-C, total cholesterol, VLDL-C, triglycerides, Lp(a ), HDL-C, LDL particle number, LDL particle size, ApoC3, ApoA-1, triglyceride-rich lipoprotein cholesterol (TRL-C), and residual cholesterol. According to certain embodiments, administering to a patient a pharmaceutical composition comprising a PCSK9 inhibitor results in an average percentage reduction of at least about 25%, 30%, 35%, 40% from baseline in serum low-density lipoprotein cholesterol (LDL-C) , 45%, 50%, 55%, 60% or more; mean percentage reduction from baseline of ApoB of at least about 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60% or Higher; mean percentage reduction from baseline of ApoB100 of at least about 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60% or more; mean percentage from baseline of non-HDL-C A reduction of at least about 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60% or more; a mean percent reduction from baseline of total cholesterol of at least about 10%, 15%, 20%, 25%, 30%, 35%, 40% or greater; mean percent reduction from baseline in VLDL-C of at least about 5%, 10%, 15%, 20%, 25%, 30% or greater; from glycerol The mean percent reduction from baseline of triesters is at least about 5%, 10%, 15%, 20%, 25%, 30%, 35% or greater; mean percent reduction from baseline in LDL particle number of at least about 20%, 25%, 30%, 35%, 40%, 45%, 50% or greater; mean from baseline in LDL particle size A percent decrease of at least about 1.5%, 2%, 2.5%, 3%, 3.5%, or 4% or more; a mean percent decrease from baseline of apolipoprotein C3 (ApoC3) of at least about 5%, 5.5%, 6.0%, 6.5%, 7.0%, 7.5%, 8.0%, 9.0%, 10% or more; mean percentage increase from baseline in HDL-C of at least about 1%, 2%, 3%, 4%, 5% or more ; mean percentage increase from baseline of ApoA-1 of at least about 1%, 2%, 3%, 4%, 5% or higher; mean percentage decrease of at least about 5%, 10%, 15% from baseline of TRL-C %, 20%, 25%, 30% or higher; and/or a mean percentage decrease from baseline of Lp(a) of at least about 5%, 10%, 15%, 20%, 25% or higher.

The methods of the present invention include treating patients with hypercholesterolemia and T1DM who are receiving insulin therapy, the method comprising administering in an amount of about 75 to 150 mg per dose, and at a frequency of about once every two weeks or every four weeks, Alternatively, multiple doses of the anti-PCSK9 antibody or antigen-binding fragment thereof are administered to the patient according to the dosing regimen of the ascending titration dosing regimen disclosed herein. Patients may demonstrate at least a 35%, 50%, or 60% reduction in LDL-C levels from baseline after approximately 8, 10, 12, 14, 16, 18, 20, 22, 24, or more weeks of treatment with an anti-PCSK9 antibody . In certain embodiments, the patient exhibits a reduction in LDL-C levels from baseline of about 35%, 50%, or 60% or more after one or more weeks of treatment with the anti-PCSK9 antibody.

The method of the present invention also includes the treatment of patients with hypercholesterolemia and T2DM receiving insulin therapy, the method comprising administering an amount of about 75 to 150 mg per dose, and a dosing frequency of about once every two weeks or every four weeks , or according to the dosing regimen of the ascending titration dosing regimen disclosed herein, multiple doses of the anti-PCSK9 antibody or antigen-binding fragment thereof are administered to the patient. Patients may demonstrate a reduction in LDL-C levels of at least 40%, 48%, or 54% from baseline after approximately 8, 10, 12, 14, 16, 18, 20, 22, 24, or more weeks of treatment with an anti-PCSK9 antibody . In certain embodiments, the patient exhibits a reduction in LDL-C levels from baseline of about 40%, 48%, or 54% or more after one or more weeks of treatment with the anti-PCSK9 antibody.

As disclosed herein, the methods of the invention do not alter the diabetic parameters of the patient. For example, in some embodiments, the method does not affect (eg, no greater than 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, or 10% of change) patients' hemoglobin A1c (HbA1c) level. In certain embodiments, the method does not affect (e.g., does not change by more than 2%, 4%, 6%, 8%, 10%, 12%, 15%, 18%, or 20%) the patient's fasting Blood glucose (FPG) levels.

In further embodiments, the present invention relates to antibodies or antigen-binding fragments thereof that specifically bind human proprotein convertase subtilisin/kexin type 9 (PCSK9) for use in the treatment of T1DM in patients with Hypercholesterolemia use.

In yet further embodiments, the present invention relates to methods of treating hypercholesterolemia in patients with type 1 diabetes mellitus (T1DM).

In one embodiment, the use and/or method comprises the steps of:

(a) Select high cardiovascular risk patients on insulin therapy who have

(i) T1DM, and

(ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and

(b) administering 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) to the patient, wherein the patient receives concomitant insulin therapy.

In one embodiment of the use and/or method, 75 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks.

In one embodiment of the use and/or method, 150 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks.

In one embodiment of the use and/or method, 300 mg of the antibody or antigen-binding fragment is administered to the patient every four weeks.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NO: 2, 3 and 4, and SEQ ID NO: 7, 8 and 10 The three light chain CDRs shown in .

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 1, and a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 6. Amino acid sequence of the light chain variable region (LCVR).

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof is selected from the group consisting of alirocizumab, evoclizumab, bococizumab, rodixizumab, ralpancizumab and LY3015014.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof is alirixumab.

In one embodiment, the use and/or method further comprises the steps of:

(c) administering to the patient one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof approximately every two weeks if the LDL-C level in the patient is below a threshold level, or if the LDL-C level in the patient is - the C level is greater than or equal to the threshold level, then one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof are administered about every two weeks.

In one embodiment, the use and/or method further comprises the steps of:

(c) administering to the patient one or more of the following doses of 300 mg of the antibody or antigen-binding fragment thereof about every four weeks if the LDL-C level in the patient is below a threshold level, or if the LDL-C level in the patient is- If the C level is greater than or equal to the threshold level, then one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof are administered about every two weeks.

In one embodiment of the use and/or method, the threshold level is 70 mg/dL.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof is administered subcutaneously.

In one embodiment of the use and/or method, the patient further receives concomitant lipid modification therapy (LMT).

In one embodiment of the use and/or method, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids and bile acid sequestrants.

In one embodiment of the use and/or method, the LMT is statin therapy.

In one embodiment of the use and/or method, the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, Pitavastatin and cerivastatin.

In one embodiment of the use and/or method, the statin therapy is a maximally tolerated statin therapy.

In one embodiment of the use and/or method, the cholesterol absorption inhibitor is ezetimibe.

In one embodiment of the use and/or method, the patient is statin intolerant.

In one embodiment of the use and/or method, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart and basal insulin.

In one embodiment of the use and/or method, the patient is receiving concomitant anti-diabetic therapy in addition to insulin therapy.

In one embodiment of the use and/or method, the additional concomitant antidiabetic therapy is selected from the group consisting of: glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor Agonists or antagonists, glucose-dependent insulinotropic polypeptide (GIP) receptor agonists or antagonists, ghrelin antagonists or inverse agonists, xenin, xenin analogs, biguanides, sulfonylureas Classes, meglitinides, thiazolidinediones, DPP-4 inhibitors, α-glucosidase inhibitors, sodium-dependent glucose transporter 2 (SGLT-2) inhibitors, SGLT-1 inhibitors, excessive Oxisome proliferator-activated receptor (PPAR-) (alpha, gamma, or alpha/gamma) agonists or modulators, amylin, amylin analogs, G protein-coupled receptor 119 (GPR119) agonists, GPR40 agonists, GPR120 agonists, GPR142 agonists, systemic or poorly absorbed TGR5 agonists, diabetes immunotherapy, anti-inflammatory agents for the treatment of metabolic syndrome and diabetes, adenosine monophosphate Activating protein kinase (AMPK) stimulator, inhibitor of 11-beta-hydroxysteroid dehydrogenase 1, activator of glucokinase, inhibitor of diacylglycerol O-acyltransferase (DGAT), glucose transporter -4 modulators, somatostatin receptor 3 agonists, lipid-lowering agents, and combinations thereof.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof lowers the patient's LDL-C levels by at least 30%, 35%, 40% or 45%.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof reduces non-HDL-C levels in the patient by at least 25%, 30%, 35% or 40%.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof reduces apolipoprotein C3 (ApoC3) levels in the patient.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient.

In one embodiment of the uses and/or methods, the antibody or antigen-binding fragment thereof:

(a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or

(b) Does not affect the patient's fasting plasma glucose (FPG) level.

In a further embodiment, the present invention relates to uses and/or methods for the treatment of hypercholesterolemia in patients with type 1 diabetes mellitus (T1DM), the method comprising the steps of:

(a) Select high cardiovascular risk patients on insulin therapy who have

(i) T1DM, and

(ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy;

(b) administering to the patient 75 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) every two weeks; and

(c) administering to the patient one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof about every two weeks if the LDL-C level in the patient is below 70 mg/dL, or if the patient has LDL-C levels greater than or equal to 70 mg/dL, administering one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof approximately every two weeks,

wherein the antibody or antigen-binding fragment thereof comprises HCVR having the amino acid sequence of SEQ ID NO: 1 and LCVR having the amino acid sequence of SEQ ID NO: 6, and wherein the patient is receiving concomitant insulin therapy.

In a further embodiment, the present invention relates to a method for treating hypercholesterolemia in a patient with type 2 diabetes mellitus (T2DM), the method comprising the steps of:

(a) Select high cardiovascular risk patients on insulin therapy who have

(i) T1DM, and

(ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and

(b) administering 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) to the patient, wherein the patient receives concomitant insulin therapy.

In one embodiment of the use and/or method, 75 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks.

In one embodiment of the use and/or method, 150 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks.

In one embodiment of the use and/or method, 300 mg of the antibody or antigen-binding fragment is administered to the patient every four weeks.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NO: 2, 3 and 4, and SEQ ID NO: 7, 8 and 10 The three light chain CDRs shown in .

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 1 and an amine having the amino acid sequence of SEQ ID NO: 6 The amino acid sequence of the light chain variable region (LCVR).

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof is selected from the group consisting of alirocizumab, evoclizumab, bococizumab, rodixizumab, ralpancizumab and LY3015014.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof is alirixumab.

In one embodiment of the use and/or method, further comprising the following steps:

(c) administering to the patient one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof approximately every two weeks if the LDL-C level in the patient is below a threshold level, or if the LDL-C level in the patient is - the C level is greater than or equal to the threshold level, then one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof are administered about every two weeks.

In one embodiment of the use and/or method, further comprising the following steps:

(c) administering to the patient one or more of the following doses of 300 mg of the antibody or antigen-binding fragment thereof about every four weeks if the LDL-C level in the patient is below a threshold level, or if the LDL-C level in the patient is- If the C level is greater than or equal to the threshold level, then one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof are administered about every two weeks.

In one embodiment of the use and/or method, the threshold level is 70 mg/dL.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof is administered subcutaneously.

In one embodiment of the use and/or method, the patient further receives

Followed by Lipid Modification Therapy (LMT).

In one embodiment of the use and/or method, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids and bile acid sequestrants.

In one embodiment of the use and/or method, the LMT is statin therapy.

In one embodiment of the use and/or method, the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, Pitavastatin and cerivastatin.

In one embodiment of the use and/or method, the statin therapy is a maximally tolerated statin therapy.

In one embodiment of the use and/or method, the cholesterol absorption inhibitor is ezetimibe.

In one embodiment of the use and/or method, the patient is statin intolerant.

In one embodiment of the use and/or method, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart and basal insulin.

In one embodiment of the use and/or method, the patient is receiving concomitant anti-diabetic therapy in addition to insulin therapy.

In one embodiment of the use and/or method, the additional antidiabetic therapy is selected from the group consisting of: glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptides, glucagon receptor stimulating agonists or antagonists, glucose-dependent insulinotropic polypeptide (GIP) receptor agonists or antagonists, growth hormone releasing hormone antagonists or inverse agonists, xenin, xenin analogs, biguanides, sulfonylureas , meglitinides, thiazolidinediones, DPP-4 inhibitors, α-glucosidase inhibitors, sodium-dependent glucose transporter 2 (SGLT-2) inhibitors, SGLT-1 inhibitors, peroxidase Proliferator-activated receptor (PPAR-) (alpha, gamma, or alpha/gamma) agonists or modulators, amylin, amylin analogs, G protein-coupled receptor 119 (GPR119) agonists agonist, GPR40 agonist, GPR120 agonist, GPR142 agonist, systemic or low absorption TGR5 agonist, diabetes immunotherapy therapy, anti-inflammatory agents for the treatment of metabolic syndrome and diabetes, stimulators of adenosine monophosphate-activated protein kinase (AMPK), inhibitors of 11-β-hydroxysteroid dehydrogenase 1, activators of glucokinase, di Inhibitors of acylglycerol O-acyltransferase (DGAT), modulators of glucose transporter-4, somatostatin receptor 3 agonists, lipid-lowering agents, and combinations thereof.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof lowers the patient's LDL-C levels by at least 30%, 35%, 40% or 45%.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof reduces non-HDL-C levels in the patient by at least 20%, 25%, 30% or 35%.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof reduces ApoC3 levels in the patient.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient.

In one embodiment of the uses and/or methods, the antibody or antigen-binding fragment thereof:

(a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or

(b) Does not affect the patient's fasting plasma glucose (FPG) level.

In a further embodiment, the present invention relates to a use and/or method for treating hypercholesterolemia in a patient with type 2 diabetes mellitus (T2DM), the method comprising the steps of:

(a) Select high cardiovascular risk patients on insulin therapy who have

(i) T2DM, and

(ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and

(b) administering to the patient 75 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) every two weeks; and

(c) administering to the patient one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof about every two weeks if the LDL-C level in the patient is below 70 mg/dL, or if the patient has LDL-C levels greater than or equal to 70 mg/dL, then administering one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof about every two weeks, wherein the antibody or antigen-binding fragment thereof comprises the antibody having SEQ ID NO: 1 HCVR having the amino acid sequence and LCVR having the amino acid sequence of SEQ ID NO: 6, and wherein the patient is receiving concomitant insulin therapy.

In further embodiments, the present invention relates to antibodies or antigen-binding fragments thereof that specifically bind human proprotein convertase subtilisin/kexin type 9 (PCSK9) for use in the treatment of patients with type 2 diabetes mellitus (T2DM) and atherosclerosis Use for hypercholesterolemia in patients with sclerotic cardiovascular disease (ASCVD).

In yet further embodiments, the present invention relates to methods for treating hypercholesterolemia in patients with T2DM and ASCVD.

In one embodiment, the use and/or method comprises the steps of:

(a) Select high cardiovascular risk patients on insulin therapy who have

(i) T2DM,

(ii) ASCVD and

(iii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and

(b) administering 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) to the patient, wherein the patient receives concomitant insulin therapy.

In one embodiment of the use and/or method, the ASCVD is defined as coronary heart disease (CHD), ischemic stroke or peripheral arterial disease.

In one embodiment of the use and/or method, the CHD comprises acute myocardial infarction, asymptomatic myocardial infarction and unstable angina.

In one embodiment of the use and/or method, 75 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks.

In one embodiment of the use and/or method, 150 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks.

In one embodiment of the use and/or method, 300 mg of the antibody or antigen-binding fragment is administered to the patient every four weeks.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOs: 2, 3 and 4 and the three heavy chain CDRs set forth in SEQ ID NOs: 7, 8 and 10. Three light chain CDRs are shown.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 1 and an amine having the amino acid sequence of SEQ ID NO: 6 The amino acid sequence of the light chain variable region (LCVR).

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof is selected from the group consisting of alirocizumab, evoclizumab, bococizumab, rodixizumab, ralpancizumab and LY3015014.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof is alirixumab.

In one embodiment, the use and/or method further comprises the steps of:

(c) administering to the patient one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof approximately every two weeks if the LDL-C level in the patient is below a threshold level, or if the LDL-C level in the patient is - the C level is greater than or equal to the threshold level, then one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof are administered about every two weeks.

In one embodiment, the use and/or method further comprises the steps of:

(c) administering to the patient one or more of the following doses of 300 mg of the antibody or antigen-binding fragment thereof about every four weeks if the LDL-C level in the patient is below a threshold level, or if the LDL-C level in the patient is- If the C level is greater than or equal to the threshold level, then one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof are administered about every two weeks.

In one embodiment of the use and/or method, the threshold level is 70 mg/dL.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof is administered subcutaneously.

In one embodiment of the use and/or method, the patient further receives concomitant lipid modification therapy (LMT).

In one embodiment of the use and/or method, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids and bile acid sequestrants.

In one embodiment of the use and/or method, the LMT is statin therapy.

In one embodiment of the use and/or method, the statin is selected from the group into groups: atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin and cerivastatin.

In one embodiment of the use and/or method, the statin therapy is a maximally tolerated dose of statin therapy.

In one embodiment of the use and/or method, the cholesterol absorption inhibitor is ezetimibe.

In one embodiment of the use and/or method, the patient is statin intolerant.

In one embodiment of the use and/or method, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart and basal insulin.

In one embodiment of the use and/or method, the patient is receiving concomitant anti-diabetic therapy in addition to insulin therapy.

In one embodiment of the use and/or method, the additional antidiabetic therapy is selected from the group consisting of: glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptides, glucagon receptor stimulating agonists or antagonists, glucose-dependent insulinotropic polypeptide (GIP) receptor agonists or antagonists, growth hormone releasing hormone antagonists or inverse agonists, xenin, xenin analogs, biguanides, sulfonylureas , meglitinides, thiazolidinediones, DPP-4 inhibitors, α-glucosidase inhibitors, sodium-dependent glucose transporter 2 (SGLT-2) inhibitors, SGLT-1 inhibitors, peroxidase Proliferator-activated receptor (PPAR-) (alpha, gamma, or alpha/gamma) agonists or modulators, amylin, amylin analogs, G protein-coupled receptor 119 (GPR119) agonists agonists, GPR40 agonists, GPR120 agonists, GPR142 agonists, systemic or poorly absorbed TGR5 agonists, diabetes immunotherapy, anti-inflammatory agents for the treatment of metabolic syndrome and diabetes, adenosine monophosphate activation Protein kinase (AMPK) stimulator, inhibitor of 11-beta-hydroxysteroid dehydrogenase 1, activator of glucokinase, inhibitor of diacylglycerol O-acyltransferase (DGAT), glucose transporter- 4 modulators, somatostatin receptor 3 agonists, lipid-lowering agents, and combinations thereof.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof lowers the patient's LDL-C levels by at least 30%, 35%, 40% or 45%.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof reduces non-HDL-C levels in the patient by at least 20%, 25%, 30% or 35%.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof reduces ApoC3 levels in the patient.

In one embodiment of the use and/or method, the antibody or antigen-binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient.

In one embodiment of the uses and/or methods, the antibody or antigen-binding fragment thereof:

(a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or

(b) Does not affect the patient's fasting plasma glucose (FPG) level.

In a further embodiment, the present invention relates to uses and/or methods for treating hypercholesterolemia in patients with type 2 diabetes mellitus (T2DM), the methods comprising:

(a) Select high cardiovascular risk patients on insulin therapy who have

(i) T2DM,

(ii) ASCVD and

(iii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy;

(b) administering to the patient 75 mg of an antibody or antigen-binding fragment thereof that specifically binds human proprotein convertase subtilisin/kexin type 9 (PCSK9) every two weeks; and

(c) administering to the patient one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof about every two weeks if the LDL-C level in the patient is below 70 mg/dL, or if the patient has LDL-C levels greater than or equal to 70 mg/dL, administering one or more of the following doses of 150 mg of the antibody or antigen-binding fragment thereof approximately every two weeks,

wherein the antibody or antigen-binding fragment thereof comprises HCVR having the amino acid sequence of SEQ ID NO: 1 and LCVR having the amino acid sequence of SEQ ID NO: 6, and wherein the patient is receiving concomitant insulin therapy.

example

The following examples are presented to provide those of ordinary skill in the art with a complete disclosure and description of how to make and use the methods and compositions of the invention, and are not intended to limit the scope of the invention. Ming people considered the scope of their inventions. Efforts have been made to ensure accuracy with respect to numbers used (eg, amounts, temperature, etc.), but some experimental errors and deviations should be accounted for. Unless indicated otherwise, parts are parts by weight, molecular weight is average molecular weight, temperature is in degrees Centigrade, and pressure is at or near atmospheric.

Example 1: Generation of Human Antibodies to Human PCSK9

Human anti-PCSK9 antibodies were generated as described in US Patent No. 8,062,640. An exemplary PCSK9 inhibitor used in the following examples is the human anti-PCSK9 antibody designated "mAb316P", also known as "REGN727" or "alikumab". mAb316P has the following amino acid sequence characteristics: a heavy chain comprising SEQ ID NO: 5 and a light chain comprising SEQ ID NO: 9; a heavy chain variable region (HCVR) comprising SEQ ID NO: 1 and comprising SEQ ID NO: Light chain variable region (LCVR) of 6; heavy chain complementarity determining region 1 (HCDR1) comprising SEQ ID NO: 2, HCDR2 comprising SEQ ID NO: 3, HCDR3 comprising SEQ ID NO: 4, comprising SEQ ID NO Light chain complementarity determining region 1 (LCDR1) of :7, LCDR2 comprising SEQ ID NO:8 and LCDR3 comprising SEQ ID NO:10.

Example 2: Randomized, double-blind, placebo-controlled parallel group study to evaluate alirocumab in patients with type 1 or type 2 diabetes mellitus not adequately controlled on maximally tolerated LDL-C lowering therapy Efficacy and safety of insulin-treated patients with hypercholesterolemia at high cardiovascular risk

introduce

More than 380 million people worldwide live with diabetes, most of whom will die from cardiovascular disease (CVD). Compared with people without diabetes, those with diabetes are at higher risk of developing CVD, suffer from associated clinical complications and at an earlier age, and have a shortened life expectancy of about 6 to 7 years. In addition to the high in-person costs of the disease, CVD contributes significantly to the overall healthcare expenditure of these patients.

The study, named Odyssey DM-Insulin, included adult patients with type 1 or type 2 diabetes on insulin therapy with or without other lipid-modifying treatments. Hypercholesterolemia at high cardiovascular (CV) risk not adequately controlled on maximally tolerated statin therapy in the setting of (LMT).

Research purposes

The primary objectives of the study were: (a) to evaluate the efficacy of alirocumab compared with placebo in reducing calculated low-density lipoprotein cholesterol (LDL-C) after 24 weeks of treatment in patients at high cardiovascular risk who had Diabetes treated with insulin and hypercholesterolemia not adequately controlled on maximally tolerated LDL-C lowering therapy; and (b) evaluating the safety of alirocumab in patients with diabetes treated with insulin and tolerance.

The secondary objective of the study was to evaluate the efficacy of alirocumab compared to placebo on other lipid parameters (e.g., measured LDL-C, non-HDL-cholesterol (non-HDL- C), apolipoprotein B (Apo B), total cholesterol (TC), lipoprotein a (Lp(a)), high-density lipoprotein cholesterol (HDL-C), triglyceride (TG) levels, rich in glycerol Triester lipoprotein (TGRL), apolipoprotein A-1 (Apo A-1), apolipoprotein C3 (ApoC3) and LDL particle number and size).

Research design

This is a Phase 3b randomized, double-blind, placebo-controlled multinational and multicenter study to evaluate the efficacy of alirixumab administered by subcutaneous (SC) injection in patients at high CV risk and with type 1 or type 2 diabetes mellitus And efficacy and safety in insulin-treated patients with hypercholesterolemia inadequately controlled by maximally tolerated LDL-C lowering therapy. The study consists of a screening period of up to 3 weeks, a 24-week double-blind treatment period, and an 8-week safety observation period after the double-blind treatment period.

Unless patients were statin intolerant, they were on a stable, maximally tolerated dose of statin therapy with or without other lipid-modifying therapy (LMT). The dose and dose regimen of the statin and, if applicable, of one or more other lipid-modifying treatments were maintained throughout the study period (including the 4 weeks preceding the screening period, during the screening period and from screening to random assignment). is stable. Throughout the study period from screening to week 24 visit During the period, patients were on a stable diet with glucose and lipid management. Patient is being treated for diabetes according to local/regional standard of care.

Patients were stratified by diabetes type (ie, type 1 diabetes versus type 2 diabetes). Enrollment of patients with type 2 diabetes was completed when approximately 400 patients were randomly assigned. At the end of the target enrollment period, enrollment of patients with type 1 diabetes was completed.

70mg/dL(1.81mmol/L)，則以75mg Q2W的起始劑量皮下施用阿利庫單抗持續12周，在第12週用盲法上升滴定至阿利庫單抗150mg Q2W。在第8週拜訪時具有LDL-C<70mg/dL(1.81mmol/L)的患者繼續使用阿利庫單抗75mg Q2W直到治療期結束。 If LDL-C at week 8 visit

70mg/dL (1.81mmol/L), the initial dose of 75mg Q2W was administered subcutaneously with alirizumab for 12 weeks, and at the 12th week, it was titrated blindly to 150mg Q2W of alirixumab. Patients with LDL-C <70 mg/dL (1.81 mmol/L) at the Week 8 visit continued on alirocumab 75 mg Q2W until the end of the treatment period.

Data for lipid parameters from blood samples were masked after random assignment. In the investigator's judgment, no attempt was made by the investigator or the patient to independently assess the patient's lipid values after randomization until after the Week 24 visit, except for patient safety.

Patients visited the study site at Weeks -3, 0, 8, 12, 20, and 24, with laboratory work performed at each visit. In addition, telephone visits were also conducted at weeks 4 and 32.

Adverse events (AEs) occurring within 70 days of the last dose of investigational medicinal product (IMP) were recorded. Patients with serious adverse events (SAEs) or adverse events of special interest (AESIs) were followed until resolution, stabilization or death.

patient selection

A total of 517 patients were enrolled in the study, including 76 patients with T1DM and 441 patients with T2DM.

Inclusion criteria

Patients enrolled in this study met all of the following criteria:

70mg/dLLDL-C的水準(1.81mmol/L)，該穩定的、最大劑量/方案的他汀類是在篩選拜訪之前(第-3周)被患者耐受了至少4週。患者耐受的最大劑量/方案的他汀類是基於研究 者的判斷或關注的登記的患者耐受的劑量/方案。服用較低他汀類劑量的患者的可接受原因的一些實例包括但不限於對較高劑量的不良影響、高齡、低體重指數(BMI)、區域實踐、當地處方信息或伴隨藥物。患者可能已服用替代性的日劑量的他汀類，只要一致地服用該劑量(例如，每週一、週三、週五的劑量等)。不允許使用超過1種他汀類的伴隨治療。由研究者判斷，具有記錄的不耐受性並且因此不再接受他汀類治療的患者對於該研究也是符合條件的。以病案報告的形式記錄不進行最大劑量/方案的他汀類的一個或多個原因(包括他汀類不耐受)。 (1) Patients with insulin-treated type 1 or type 2 diabetes mellitus who have not been adequately controlled by a stable, maximal dose/schedule of statins with or without the use of other LMTs

A level of LLDL-C of 70 mg/d (1.81 mmol/L), the stable, maximum dose/schedule of statin was tolerated by the patient for at least 4 weeks prior to the screening visit (week -3). The maximum dose/schedule of statin tolerated by the patient is based on the investigator's judgment or the dose/schedule tolerated by the enrolled patient of interest. Some examples of acceptable reasons for patients taking lower statin doses include, but are not limited to, adverse effects on higher doses, advanced age, low body mass index (BMI), regional practice, local prescribing information, or concomitant medications. The patient may already be taking an alternate daily dose of the statin, so long as the dose is taken consistently (eg, every Monday, Wednesday, Friday dose, etc.). Concomitant therapy with more than 1 statin is not permitted. Patients with documented intolerance and therefore no longer receiving statin therapy were also eligible for the study at the discretion of the investigator. One or more reasons (including statin intolerance) for not proceeding with maximal dose/regimen of statins were documented in the case report.

18歲或具有成年法定年齡的患者，以較大者為准。 (2) When screening visits

Patients 18 years of age or of legal age of majority, whichever is greater.

(3) Patients diagnosed with type 1 or type 2 diabetes at least one year prior to the screening visit (week -3). Patients diagnosed with type 1 diabetes need to meet all of the following criteria:

(a) Diagnosed before the age of 30 years;

(b) treated with multiple daily injection regimens/basal-prandial insulin regimens or insulin pump regimens within 6 months of diagnosis; and

(c) C-peptide <0.2 pmol/mL at screening visit.

(4) Glycosylated hemoglobin (HbA1c) <10% at the screening visit (week -3). Patients with elevated HbA1c (up to 10%) were eligible if, based on the investigator's judgment, there was no plan to target low HbA1c during the study period.

(5) Patients with documented CVD history (including CHD and/or CHD risk equivalents) and/or at least one additional CV risk factor.

History of CHD includes at least one of the following:

(a) acute myocardial infarction (MI);

(b) Asymptomatic MI;

(c) Unstable angina;

(d) Coronary revascularization procedures (eg, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)); and

(e) Clinically significant CHD diagnosed by invasive or non-invasive testing such as coronary angiography, stress testing using a treadmill, stress echocardiography, or nuclear imaging.

CHD risk equivalents include at least one of the following:

(a) Documented peripheral arterial disease meeting at least one of the following criteria:

0.90； (i) Current intermittent claudication (muscle discomfort of the lower extremities that is reproducible and produced by exercise and relieved by rest within 10 minutes) (presumed to be of atherosclerotic origin), while ankle-brachial in either leg at rest Index (ankle-brachial index)

0.90;

(ii) History of intermittent claudication (muscle discomfort of the lower extremities that is reproducible and produced by exercise and relieved by rest within 10 minutes) and concomitantly due to atherosclerotic disease in one or both legs Endovascular procedures or surgical interventions; and

(iii) History of critical limb ischemia with concomitant thrombolysis, endovascular procedure or surgical intervention in one or both legs due to atherosclerotic disease; and

(b) Documented prior ischemic stroke with focal ischemic neurological deficit lasting more than 24 hours, the origin of which was thought to be atherosclerotic. Computed tomography or magnetic radioimaging must be performed to rule out hemorrhage and nonischemic neurological disease.

Cardiovascular risk factors include at least one of the following:

(a) Hypertension (established on antihypertensive drugs);

(b) current smoker;

45歲的男性，

55歲的女性； (c)

45 year old male,

55-year-old female;

(d) History of micro/macroalbuminuria;

(e) History of diabetic retinopathy (pre-proliferative or proliferative);

(f) Family history of premature CHD (father or brother before age 55; mother or sister before age 65);

(g) Low HDL-C (men <40mg/dL (1.0mmol/L), women <50mg/dL (1.3mmol/L)); and

eGFR<60mL/min/1.73m²限定的慢性腎病(CKD)。 (h) Recorded by 15 years old lasting 3 months or more (including screening visits)

Chronic kidney disease (CKD) defined by eGFR<60mL/min/1.73m ² .

(6) Signed written informed consent.

exclusion criteria

Patients meeting all the above inclusion criteria were screened for the following exclusion criteria:

(1) Exclusion criteria related to research methods:

(a) plan to start a new LMT or modify the dose of the current LMT during the study;

(b) No, for at least 4 weeks before the screening visit (week -3) or during the period from screening to random allocation, a stable dose of LMT (including statins or other LMTs), unless statin intolerance, in This condition lasted 4 weeks prior to the screening visit/did not take statin therapy during the screening period;

(c) Not using nutraceuticals or over-the-counter medications that may affect lipids at stable doses for at least 4 weeks prior to the screening visit (week -3) or between the screening and random assignment visits;

(d) use of red fermented rice products within 4 weeks of the screening visit (week -3) or between screening and random assignment visits;

(e) Use of systemic corticosteroids unless a stable regimen for at least 6 weeks prior to randomization is used as an alternative treatment for pituitary/adrenal disease. Topical, intra-articular, nasal, inhaled and ophthalmic steroid treatments are not considered "systemic" and are permitted;

(f) Using continuous hormone replacement therapy, unless the regimen has been stable in the 6 weeks prior to the screening visit (week -3) and there are no plans to change the regimen during the study;

(g) MI, unstable angina leading to hospitalization, uncontrolled arrhythmia, CABG, PCI , carotid artery surgery or stenting, stroke, transient ischemic attack (TIA), endovascular procedure or surgical intervention for peripheral vascular disease;

(h) Planning to perform scheduled PCI, CABG, carotid artery or peripheral revascularization during the study period;

(i) Medical history of New York Heart Association (NYHA) class III or IV heart failure (see Table 1) within the past 12 months;

(j) Systolic blood pressure > 180mmHg or diastolic blood pressure > 110mmHg at screening or random assignment visit;

(k) Patients who have received plasmapheresis treatment or plan to receive plasmapheresis treatment within 2 months before the screening visit (week -3), between screening and random allocation;

(l) Known history of hemorrhagic stroke;

(m) Known history of PCSK9 loss-of-function (i.e., genetic mutation or sequence variation) or known history of homozygous familial hypercholesterolemia;

(n) New cancer or positive progression of cancer within the past 5 years, other than adequately treated basal cell skin cancer, squamous cell skin cancer, or cervical carcinoma in situ;

(o) Known history of positive HIV test;

(p) Patients who have taken any effective investigational drug within 1 month or 5 half-lives (whichever is longer);

(q) Patients who did not receive prior cholesterol-lowering dietary guidance prior to the screening visit (week -3);

(r) Patients who withdraw consent during screening (starting with signed ICF);

(s) Unstable body weight defined as a change of >5 kg as judged by the Investigator within 2 months prior to the Screening Visit;

(t) BMI>45kg/m2 or plan to undergo bariatric surgery, weight loss program or start weight loss drugs during the course of the study;

(u) Recent initiation of bariatric medication (i.e., within 3 months prior to the screening visit or between screening and randomization) or recent bariatric surgery (within the past 6 months) and ineffective as judged by the investigator During the weight loss phase;

(v) Not receiving insulin therapy for at least 6 months prior to the Screening Visit or not on a stable insulin regimen for at least 3 months prior to the Screening Visit (i.e. changes in insulin type, general timing/frequency of injections, mode of administration or Patients with modalities such as basal-only (type 2 diabetes), basal-meal, etc.), or the possibility of needing to change insulin type/frequency or injection pattern during the study;

(w) Has not been on a stable insulin dose for at least 3 months prior to Screening (i.e., a change in total daily insulin dose of more than 30%, as judged by the Investigator), or requires intensive insulin during the course of the study, as judged by the Investigator /Possibility of antihyperglycemic drug regimen (eg, addition of new agents, plan for titrating insulin dose, etc.);

(x) Other antihyperglycemic drugs taken by the patient have been unstable for at least 3 months before the screening visit;

(y) Recent history of diabetic decompensation (i.e., diabetic ketoacidemia or hyperosmolar hyperglycemic state (HHS)) within 2 months prior to the screening visit;

(z) Receive or plan to receive renal replacement therapy (for example, hemodialysis, kidney transplantation, etc.) during the study period;

(aa) Presence of any clinically significant uncontrolled endocrine disease known to affect serum lipids or lipoproteins. If the dose of thyroxine has been stable for at least 3 months prior to screening and the patient's sensitive thyroid-stimulating hormone (s-TSH) level is within ±10% of the laboratory's normal range at the screening visit, a test may be included. Patients on thyroid replacement therapy;

(bb) Laboratory Findings During Screening (excluding random assignment laboratory, except pregnancy test):

(i) Serum TG>400mg/dL (4.52mmol/L) (1 repeat laboratory allowed);

(ii) positive serum or urine pregnancy test in women of childbearing potential;

(iii) positive test for hepatitis B surface antigen or hepatitis C antibody;

(iv) eGFR<15mL/min/1.73m2 according to the 4-variable dietary modification in renal disease (MDRD) equation;

(v) ALT or AST >3 x ULN (1 repeat lab allowed); or

(vi) Creatine phosphokinase (CPK) >3 x ULN (1 replicate laboratory allowed); or

(cc) conditions/circumstances such as:

(i) patients with short life expectancy;

(ii) the need for concomitant therapy that may deviate from the original assessment;

(iii) inability to meet specific protocol requirements (eg, need for hospitalization, ability to conduct research visits, etc.);

(iv) The patient is the investigator directly involved in the implementation of the protocol or any associate investigator, research assistant, pharmacist, research coordinator, other staff or their relatives;

(v) non-cooperation or any situation that may make the patient likely not to comply with the study procedures;

(vi) any technical/administrative reasons that prevent patients in the study from being randomly assigned; or

(vii) Any clinically significant abnormality identified at Screening that, in the judgment of the Investigator or Associate Investigator, would preclude safe completion of the study or limit the evaluation of endpoints, such as major systemic disease, patients with short life expectancy.

Table 1: New York Heart Association (NYHA) Functional Classification of Heart Failure

(2) Exclusion criteria related to active comparator and/or mandatory background treatment: all contraindications or use warnings/precautions (where appropriate) for background treatment shown in the corresponding national product label.

(3) Exclusion criteria related to current knowledge of alirixumab:

(a) Hypersensitivity to alirizumab or to any component of alirixumab;

(b) pregnant or breastfeeding women;

(c) Women of childbearing potential who are not protected by highly effective birth control methods (where specific local requirements exist, as defined in the ICF and/or local agreement appendices) and/or are unwilling or unable to undergo pregnancy testing women. Women of childbearing potential must have a confirmed negative pregnancy test at the screening and enrollment visits. They must use effective contraception throughout the study treatment period and for at least 10 weeks after the last IMP injection. The contraceptive method used must comply with the "International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use. M3 (R2): Guidance on nonclinical safety studies for the conduct of human clinical trials and marketing Authorization for pharmaceuticals. ICH. 2009 Jun: Criteria for Highly Effective Birth Control Methods 1-25". Postmenopausal women must be amenorrhea for at least 12 months.

study treatment

Research Medicinal Products

Alicuol is supplied sterile at concentrations of 75 mg/mL and 150 mg/mL in an autoinjector (also known as a prefilled pen) in an aqueous buffer (pH 6.0) containing sucrose, histidine, and polysorbate 20 Monoclonal antibody drug products, both in 1 mL volume. Prepare a sterile placebo of alirixumab in the same formulation as alirixumab without added protein in a volume of 1 mL in a prefilled pen for use in patients for injection training and for placebo Those patients in the treatment arm (arm). During screening, the patient (or another designated person) must perform a placebo self-injection training using a prefilled pen prior to the first administration of the IMP.

70mg/dL(1.81mmol/L)，則對於隨機分配到阿利庫單抗的患者，在第12週時以盲法方式增加劑量至150mg Q2W。隨機分配到安慰劑的患者在整個24週治療期間Q2W皮下被施用他們的注射。 For patients randomized to alirocumab, the initial dose was 75 mg subcutaneously once Q2W. If the LDL-C value at week 8

70mg/dL (1.81mmol/L), then for patients randomly assigned to alirizumab, the dose was increased to 150mg Q2W in a blinded manner at week 12. Patients randomized to placebo were administered their injections Q2W subcutaneously throughout the 24-week treatment period.

Routes and Methods of Administration

Provide sites with prefilled pen training guides (autoinjector training guides) and patients with instructions for use (using an autoinjector). Each administration of IMP consisted of a 1 mL subcutaneous injection in the abdomen, thigh, or external region of the upper arm (ie, deltoid region). If an additional concomitant drug is injected at the same site planned for IMP injection, advise the patient to use the alternate site for IMP administration.

IMPs can be administered by self-injection or by another designated person (eg, spouse, relative, etc.). If a person is designated to administer alirixumab to patients during the study, it should be ensured that the person is adequately trained before administering the injection. Anyone who plans to administer the IMP is trained by the investigator.

During training and as needed during the study, patients (or administered injections) another designated person (eg, spouse, relative, etc.)) to provide clarification. Close monitoring and feedback was given at the first visit and at other visits as needed.

Discard the used prefilled pen in the sharps container provided to the patient. Rotation of subcutaneous IMP injections within the anatomical region is recommended (eg, right thigh, then left thigh or right abdomen, then left abdomen). During the study, patients also had the option of injections in different anatomical regions (eg, thigh and then abdomen, or the outer region of the upper arm, etc.).

Ask the patient to store the IMP in the refrigerator. The IMP should be left outside at room temperature in a safe location for about 30 to 40 minutes prior to application. Thereafter, the IMP should be administered as soon as possible.

Timing of administration

During the screening period, the patient or designated person must undergo a placebo self-injection training using a pre-filled pen prior to the first IMP injection.

At the randomization visit, the first IMP injection is administered on-site by the patient or another designated person (such as a spouse, relative, etc.) under direct on-site staff supervision. Patients were monitored at the study site for at least 30 minutes after the first injection in the study. If the assigned person is changed during the study, the newly assigned person will be trained with a placebo.

Subcutaneous injections of IMP were then administered outside the clinic, Q2W until the last injection. If the injection is scheduled to occur on the same day as the site visit, the IMP is performed after the blood sampling is completed. In exceptional cases, this is also allowed if the patient prefers to have the injections administered at the study site and can make provision to accommodate administration of the injections at the site.

IMP should be administered Q2W subcutaneously, ideally at about the same time of day. However, it is acceptable to have a window period of ±3 days. Time of day is based on patient preference.

If, by mistake or due to other circumstances, the injection was delayed more than 7 days from the missed date or missed entirely, the patient was asked to return to the original schedule of IMP administration without administering the delayed injection. If, by mistake or due to other circumstances, the injection is delayed by less than or equal to 7 days from the missed date, the patient is asked to administer the delayed injection and then restart the original schedule of IMP administration.

non-investigational drug

Drugs in the following classes are identified as non-IMPs because the drug is background therapy or Potential rescue drugs:

(a) statins;

(b) Cholesterol absorption inhibitors (ezetimibe);

(c) bile acid-binding chelators (eg, cholestyramine, colestipol, colesevelam);

(d) Nicotinic acids;

(e) fibrates (such as fenofibrate);

1000mg)；和 (f) omega-3 fatty acids (daily

1000mg); and

(g) Insulin.

For background LMTs including statins, sites follow national product labels for patient safety monitoring and management. During the study period, patients received a stable, maximally tolerated statin dose/schedule with or without other LMTs. Lipid profile values were obtained blinded from samples obtained after random allocation. However, for safety reasons, the scene was made to inform the TG alert with the aim of making a decision on the patient's background LMT.

Background LMT was unchanged from the Screening Visit (Week -3) until the Week 24 Visit. During this period, no dose adjustments, discontinuation or initiation of other statins or other LMTs will be undertaken unless such overriding concerns (including but not limited to TG alerts issued by the central laboratory) justify such changes in the judgment of the Investigator exceptions. For TG alerts that have been confirmed by repeat testing, the investigator conducts the investigation, manages the patient, and modifies the background LMT according to his/her medical judgment.

All fibric acid was allowed in if the patient had tolerated the drug and remained on a stable dose. Addition of fenofibrate was only permitted if the patient required the introduction of fibric acid during the course of the study (ie, as rescue therapy in response to a TG alert). Background LMT and insulin were provided by the sponsor. Patients obtained these medications in accordance with local regulations.

blind procedure

Alirocumab and alirocumab placebo were provided in identical matched pre-filled pens and identically packaged, which included labeling to protect blinding. Each treatment kit is labeled with a number, which is generated by the sponsor's computer program. The treatment kit number was obtained by the investigator at the time of patient randomization and subsequent patient visits scheduled via the IVRS/IWRS, which The IVRS/IWRS are available 24 hours a day, 7 days a week.

According to the double-blind design, study patients, investigators, and study site personnel remained blinded to study treatment and had no access to random assignment (treatment code) except as described below.

Adverse event

Treatment codes were unblinded by the Pharmacovigilance Unit for reporting to the Health Authority any suspected Unexpected Serious Adverse Reactions (SUSARs), i.e. unexpected according to the investigator's and/or sponsor's judgment (CIB each specific sector) and are reasonably related to the use of IMPs.

lipid parameters

500mg/dL的TG警報發送給研究者。 Lipid parameter values from blood samples obtained after the random assignment visit by the central laboratory were not communicated to the site so that they could not infer their patients' treatment groups based on the LDL-C levels obtained. , the sponsor's operations team will not have access to lipid parameters relevant to patient identification until a final database lock occurs. For security purposes, any time after random assignment the TG value

A TG alert of 500 mg/dL was sent to the investigator.

At the end of the double-blind treatment period (Visit Week 24), investigators continued to manage patients' lipids according to standard practice. Any lipid values after randomization were written in the source file and were not shared with the sponsor.

anti-aliricumab antibody

Patient anti-alirixumab antibody results were not communicated to the site while the study was ongoing. Anti-alirixumab antibody results associated with patient identification numbers were not available to the sponsor's operations team until the final database lock occurred. Laboratory technicians involved in determining the patient's anti-alirixumab antibody titer were excluded from the operating team, and a method was established to prevent any potential unblinding.

Randomly assign codes to break during the study

In the case of an AE, where knowledge of the IMP is required to treat the patient, Break the password. If possible, start contacting the monitoring team/study physician before breaking the code. When appropriate, all calls were recorded by the monitoring team to include the date and time of the call, the name of the person contacted within the monitoring team, patient ID, requested documentation, and the decision to unblind.

Code destruction may be performed at any time by using the appropriate module of the Interactive Voice Response System (IVRS)/Interactive Web Response System (IWRS), depending on which system is used on-site, and/or for that purpose by dialing the Any other phone number provided. However, it is advisable to contact the study physician to discuss the case before unblinding the case. If blinding is broken, the investigator is asked to record the date, time and reason for the code break and report this information on the appropriate page of the e-CRF. When documenting the reasons for unblinding, the investigators did not provide any details about the nature of the IMP. Investigators did not disclose IMP details to sponsor's representatives or any staff until the database was closed. In addition, when the forms (eg, AE, SAE) were completed, the study treatment was not disclosed on the forms.

Code-breaking material is also kept at the entity responsible for the "24-hour alert system"; however, this system should only be used in very exceptional circumstances (i.e. the IVR/IWR system cannot be used or the investigator and/or field staff cannot be contacted). However, the preferred option is to use IVRS unblinding. The availability of local code-breaking materials was reported to the investigator by the clinical monitoring team. A patient card, including the relevant "24-hour alert system" telephone number, is provided to each patient participating in the study. Sponsors are also allowed to unblind some SAEs to comply with regulatory reporting requirements (ie, for some SAEs that are both relevant and unexpected).

If the code is broken, the patient permanently discontinues IMP administration.

Method of assigning patients to treatment groups

A randomly assigned list of treatment kit numbers was generated centrally by the sponsor. The IMP (alirocumab 75 or 150 mg kit, or placebo kit) was packaged according to this list.

The trial supply operations manager provided the random assignment list of treatment kit numbers, and the study biostatistician provided the random assignment scheme to the centralized treatment assignment system provider. The centralized treatment allocation system provider then generates a patient random allocation list from which treatments are assigned to patients.

During the double-blind treatment period, patients were randomly assigned to receive placebo or alirocumab. The randomization ratio alirixumab:placebo was 2:1. For each randomized patient, there is Several corresponding treatment kit numbers (re-provided visits), which are distributed through the centralized treatment distribution system. Randomization will be stratified by type of diabetes (ie type 1 versus type 2).

Treatment kit numbers were assigned using the centralized treatment assignment system at random assignment visits (Day 1, Week 0), then at Week 12 as a re-offer visit, and if required at unscheduled visits.

For patients in the alirocumab treatment arm, the treatment kit assigned at week 12 was based on the patient's week 8 LDL-C level following the ascending titration rule. Periodic data transfers between central laboratories and centralized treatment allocation system providers are planned to be performed in a blinded manner to study sites and sponsors.

Before randomizing patients, the investigator or designee must contact the centralized treatment allocation system.

A randomized patient was defined as a patient enrolled and allocated using a treatment kit number from the centralized treatment allocation system, as documented in its log file. Patients cannot be randomly assigned more than once in the study. If a treatment was used without linking to the centralized treatment allocation system, the patient was considered not randomized and withdrawn from the study.

Depending on the site's choice, two types of centralized treatment distribution systems are used, IVRS and IWRS.

Packaging and Labeling

For the double-blind treatment period, each double-blind treatment kit (alirocumab or placebo for alirocumab) was prepared to contain 6 pre-filled pens in a child-resistant package. To protect blinding, all double-blind treatment kit boxes for injections will have the same look and feel and will therefore be labeled with a double-blind label.

In addition to the double-blind treatment kit for injection, a training kit containing 1 placebo prefilled pen of alirocumab was prepared for the purpose of instructing patients on injection administration, which was performed at the screening visit (p. -3 weeks, prior to randomization at first visit). If deemed necessary, a second training injection of placebo with alirocumab was administered using an additional training kit prior to randomization. Injection training with placebo is performed and recorded in the CRF, this includes if the assigned person administering the IMP to the patient changes during the course of the study.

The packaging is in accordance with the intended application plan. The content of the label complies with local regulatory codes and requirements.

Storage conditions and storage period

The investigator or other authorized personnel (eg, pharmacist) is responsible for storing the IMP in an secure and secure location according to local regulations, labeling specifications, policies, and procedures. Control of storage conditions of the IMPs was governed according to rules provided by the sponsor, especially temperature control (eg, refrigerated storage) and information on stability in use and instructions for handling the IMPs.

IMPs are stored on site in refrigerators between +2°C and +8°C (36°F and 46°F). The temperature of the on-site refrigerator is checked daily and recorded on a log sheet. IMPs stored on the study site are kept in properly locked rooms under the responsibility of the investigator or designee or other authorized personnel according to the storage conditions indicated on the label.

Following supply of IMP kits to patients at study site visits, appropriate provisions were made to transfer the IMP kits from the study site to the patient's refrigerator.

study endpoint

Baseline characteristics include each patient's standard demographics (eg, age, race, weight, height, etc.), disease characteristics (including medical history), and medication history.

primary efficacy endpoint

The primary efficacy endpoint was the percent change in LDL-C from baseline to week 24 in the intent-to-treat (ITT) population, using all LDL-C values regardless of adherence to treatment (ITT was assessed). Percent change is defined as 100x (LDL-C value calculated at week 24 - LDL-C value calculated at baseline)/LDL-C value calculated at baseline.

Baseline calculated LDL-C values were the last LDL-C levels obtained before the first double-blind IMP injection. LDL-C calculated at week 24 is the LDL-C level obtained within the analysis window of week 24. Values for the primary efficacy endpoint were allowed using all calculated LDL-C values (planned or unscheduled, fasted or not) between weeks 8 and 24, as defined above, if appropriate .

Primary Safety Endpoint

Safety parameters (AEs, laboratory parameters, vital signs) were assessed throughout the study. The safety data observations are as follows:

(a) The pre-treatment period is defined as the period from signed informed consent until the first dose of double-blind IMP injection;

(b) The treatment-emergent adverse event (TEAE) period is defined as the time from the first dose of double-blind IMP injection to the last dose of IMP injection + 70 days (10 weeks), as residual effects of treatment are expected until after discontinuation of double-blind IMP 10 weeks; and

(c) The post-treatment period was defined as the time from the day after the end of the TEAE period until resolution/stabilization of all SAEs and AESIs, whichever came later.

An AE is any untoward medical occurrence in a patient administered a drug product or in a clinical study patient and which does not necessarily have to be causally related to the treatment.

A SAE is any untoward medical event, at any dose, characterized by:

(a) causes death;

(b) Threat to life. The term "life-threatening" in the definition of "serious" refers to an event in which the patient is at risk of death at the time of the event; it does not refer to an event that is assumed to result in death if it is more serious;

(c) requires inpatient hospitalization or prolongation of existing hospitalization;

(d) results in persistent or significant disability/incapacity;

(e) is a congenital anomaly/birth defect; or

(f) is a medically important event.

Exercise medical and scientific judgment in determining whether expedited reporting is appropriate in other circumstances, such as situations that may not be immediately life-threatening or result in death or hospitalization but may endanger the patient or may require medical or surgical intervention (i.e. specific action or corrective treatment) to prevent one of the other outcomes listed in the definition above.

The following list of medically significant events is intended to be used as a guide for determining which conditions must be considered medically significant. This list is not exhaustive:

(a) Intensive therapy in the emergency room or at home for allergic bronchospasm, dyscrasia (ie, agranulocytosis, aplastic anemia, myelodysplasia, myelodysplasia, cytopenias of various types, etc.), or convulsions (seizures, epilepsy, epileptic fit, absence, etc.));

(b) developing drug dependence or drug abuse;

(c) ALT >3 x ULN + total bilirubin >2 x ULN or asymptomatic ALT increase >10 x ULN;

(d) attempted suicide or any incident suggesting suicide;

(e) Syncope, loss of consciousness (unless documented as a result of blood sampling);

(f) Bullous rash;

(g) Cancer diagnosed or aggravated during the study period;

(h) Chronic neurodegenerative disease (newly diagnosed) or exacerbated during the study period; and

(i) Suspected transmission of an infectious agent, if any suspected transmission of an infectious agent via a drug product (eg product contamination).

Adverse events of special interest (AESI) are AEs (serious or non-serious) that require monitoring, recording and management in a pre-specified manner. For this study, AESI is:

3×ULN(如果基線ALT<ULN)或ALT

基線值的2倍(如果基線ALT

ULN)； (a) Increase of ALT: ALT

3 x ULN (if baseline ALT < ULN) or ALT

2 times the baseline value (if the baseline ALT

ULN);

(b) Hypersensitivity events: allergic drug reactions and/or local injection site reactions considered by the investigator to be allergic (or have allergic components), which require consultation with another physician for further evaluation of hypersensitivity based on the investigator's medical judgment Reactions/allergies should be reported as AESI;

(c) Pregnancy: During the study period or within 70 days after the last dose of study drug, the female patient or the partner of the male patient (if the female partner and the local regulatory agency allow it) have a pregnancy. In all cases, pregnancy was recorded as AESI. A pregnancy is considered an SAE only if it meets one or more of the SAE criteria. In the event of pregnancy in a female patient included in the study, discontinue study product. Follow-up of pregnancy is mandatory until the results have been determined;

(d) Symptomatic IMP overdose. Overdose (accidental or intentional) was an event suspected by the investigator or spontaneously notified by the patient (not based on systematic injection counts) and was defined as at least two expected doses within the expected treatment interval (i.e., within <7 2 or more applications within a calendar day Injection), reported using the term "symptomatic overdose (accidental or intentional)", indicating the situation in brackets (for example, "symptomatic of)"). Monitor patients and institute appropriate symptomatic treatment. Circumstances of overdose are specified verbatim and symptoms, if any, are entered on a separate AE/SAE form. Asymptomatic overdoses are required to be reported as standard AEs;

(e) Neurological events: Neurological events requiring additional tests/procedures and/or referral to a specialist are required to be reported as AESI. If the event does not require additional investigations/procedures and/or referral to a specialist, it is required to be reported as a standard AE; and

(f) Neurocognitive events: All neurocognitive events are considered AESI.

Secondary Efficacy Endpoints

The key secondary endpoints of the study are as follows:

(a) Percent change in calculated LDL-C from baseline to Week 24, using all LDL-C values during efficacy treatment (on-treatment estimand);

(b) Percent change in measured LDL-C from baseline to Week 24 (ITT estimand);

(c) Percent Change in Calculated LDL-C from Baseline to Week 12 (ITT Estimated);

(d) Percent change in measured LDL-C from baseline to week 12 (ITT is estimated);

(e) Percent change in non-HDL-C from baseline to week 24 (ITT estimated);

(f) Percent change in Apo B from baseline to week 24 (ITT is estimated);

(g) Percent Change in Total Cholesterol from Baseline to Week 24 (ITT Estimated);

(h) Proportion of patients achieving LDL-C <70 mg/dL at week 24 (measured on treatment);

(i) Proportion of patients achieving LDL-C <50 mg/dL at Week 24 (measured on-treatment);

(j) Proportion of patients achieving non-HDL-C <100 mg/dL at Week 24 (measured on-treatment);

(k) Proportion of patients achieving non-HDL-C < 80 mg/dL at week 24 (measured on treatment);

(l) Percent change in Lp(a) from baseline to week 24 (ITT is estimated);

(m) Percent change in HDL-C from baseline to week 24 (ITT is estimated);

(n) Percent change in TG from baseline to Week 24 (ITT is estimated);

(o) Percent change in LDL-C particle count from baseline to Week 24 (ITT was assessed); and

(p) Percent change in LDL-C particle size from baseline to week 24 (ITT estimated).

The following diabetes-related endpoints were also measured in the study:

(a) Absolute change in HbA1c from baseline to Weeks 12 and 24 (ITT Estimated and On-Treatment Estimated);

(b) Absolute change in FPG from baseline to Weeks 12 and 24 (ITT Estimated and On-Treatment Estimated);

(c) Absolute change in total daily insulin dose (ITT Estimated and On-Treatment Estimated) from Baseline to Weeks 12 and 24; and

(d) Absolute change in number of glucose-lowering treatments from baseline to weeks 12 and 24 (ITT estimated and on-treatment estimated).

Additional efficacy endpoints of the study included:

(a) Percent Change in Calculated LDL-C from Baseline to Week 12 (Estimated On-Treatment);

(b) Percent change in measured LDL-C from baseline to Weeks 12 and 24 (measured on-treatment);

(c) Non-HDL, Apo B, total cholesterol, Lp(a), HDL-C and Percent change in TG;

(d) Proportion of patients achieving calculated LDL-C < 50 and also < 70 mg/dL at Week 12 (ITT Measured and On-Treatment Measured) and Week 24 (ITT Measured);

(e) Proportion of patients with a 50% or greater reduction in calculated LDL-C from baseline at weeks 12 and 24 (ITT was estimated);

(f) Proportion of patients achieving non-HDL-C < 80 mg/dL and also < 100 mg/dL at Week 12 (ITT Measured and On-Treatment Measured) and Week 24 (ITT Measured);

(g) Proportion of patients achieving Apo B <80 mg/dL at Weeks 12 and 24 (ITT Estimated and On-Treatment Estimated);

(h) Percent change in LDL-C particle number and size from baseline to Week 12 (ITT Estimated and On-Treat Estimated) and Week 24 (On-Treat Estimated);

(i) Percent change in TGRL, Apo A-1 and Apo C-III from baseline to Week 12 and to Week 24 (ITT Estimated and Treatment Estimated);

(j) Absolute change in ratios Apo B/Apo A-1 and TC/HDL-C from baseline to Week 12 and to Week 24 (ITT Estimated and On-Treatment Estimated);

8%，第12週和第24週達到計算的LDL-C<70和<50mg/dL的患者的比例(ITT被估量和治療中的被估量)；和 (k) based on baseline A1c < 8% or

8%, the proportion of patients achieving calculated LDL-C <70 and <50 mg/dL at Weeks 12 and 24 (ITT Estimated and On-Treatment Estimated); and

中值A1c，在第12週和第24週達到計算的LDL-C<70mg/dL和<50mg/dL的患者的比例(ITT被估量和治療中的被估量)。 (l) Based on baseline A1c < median A1c or

Median A1c, proportion of patients achieving calculated LDL-C <70 mg/dL and <50 mg/dL at Weeks 12 and 24 (ITT Estimated and On-Treatment Estimated).

research program

The window period for week 0 is +3 days. The window period at weeks 8, 12, and 24 was ±3 days. The window period at weeks 4, 20, and 32 was ±7 days. For all visits after Day 1/inclusion visit, if one visit date changed, the next visit was performed according to the original schedule outlined in Figure 1.

blood sampling

All blood sampling, including for determination of lipid parameters (e.g., TC, LDL-C, HDL-C, TG, non-HDL-C, Apo A, Apo B, Apo C-III, Lp(a), LDL particle size and Quantity) and blood sampling for determination of blood glucose, for all site visits throughout the study in the morning, under fasted conditions (ie, overnight, fasting for at least 10 to 12 hours, and no smoking), and prior to IMP injection. Avoid alcohol consumption within 48 hours and vigorous physical activity within 24 hours before blood sampling. If the patient is not fasting, no blood sample is collected and the patient is given a new appointment for the next day (or as close to that date as possible) with instructions to fast (see Conditions above).

lab testing

Collect laboratory data according to the study planning form outlined in Figure 1 and the following guidelines:

(a) Hematology: All visits except Weeks 4 and 20; may be performed at Week 0 if applicable and may be based on the investigator's clinical judgment;

(b) Chemistry: All visits except Visits 3 and 6; may be performed at Week 0 if applicable and may be performed based on investigator's clinical judgment, except for blood glucose which should be performed on all patients at Week 0 outside;

(c) HbA1c: screening and weeks 0, 12 and 24;

(d) Lipid panel: screening and weeks 0, 8, 12, 20 and 24;

(e) Measured LDL-C via beta quantification: Weeks 0, 12 and 24;

(f) Other lipid assessments (Apo B, Apo A-1, Apo C-III, LDL particle size and number, Lp[a]): Weeks 0, 12, and 24;

(g) Liver panel: All visits except visits 3 and 6; may be performed at week 0 if applicable and may be performed based on the clinical judgment of the investigator. In cases where total bilirubin values are above the normal range, differentiation into conjugated and unconjugated bilirubin occurs automatically;

(h) Creatine phosphokinase (CPK): All visits except Visits 3 and 6; if applicable at Week 0 and may be based on the investigator's clinical judgment;

(i) Hepatitis B surface antigen: screening only;

(j) Antibody to Hepatitis C: At Screening and Week 24; Antibody to Hepatitis C should be determined in case of ALT increase during the study. Reflex testing if positive for hepatitis C antibodies during the study;

(k) Pregnancy test (in women of childbearing potential only): serum pregnancy test at screening only, urine pregnancy test at weeks 0 and 24;

(l) Thyroid-stimulating hormone: For patients who are taking thyroid hormone replacement, only screening;

(m) C-peptide: screening only;

(n) PCSK9 level: Week 0 only; and

(o) Anti-alirocumab antibodies (weeks 0, 12 and 24).

urine sampling

Urinalysis will be performed at Screening and at the Week 24 Visit. Dipstick tests were performed and assessed for pH, specific gravity, and presence of blood, protein, glucose, ketones, nitrate, leukocyte esterase, urobilinogen, and bilirubin. If the strip is abnormal, standard microscopy check. Microscopic evaluation for the presence of red blood cells (RBCs), RBC clumps, white blood cells (WBCs), WBC clumps, epithelial cells (transitional, tubular, and squamous), casts (hyaline, epithelial) , WBC casts, RBC casts, granular casts, fat casts, cellular casts, broad casts, waxy casts), crystals (triphosphate crystals, calcium oxalate crystals, calcium phosphate crystals, calcium carbonate crystals, Uric acid crystals, amorphous crystals, ammonium biurate crystals, bilirubin crystals, leucine crystals, tyrosine crystals, cystine crystals), bacteria, yeast buds, yeast hyphae, trichomonas, oval fat bodies, Fat, mucus and sperm.

Spot urine tests for albumin and creatinine were performed to calculate the albumin:creatinine ratio at screening and the week 24 visit. Recheck any clinically relevant abnormal laboratory values immediately before making any decisions about the patient in question.

physical examination

Do a general physical examination. If new clinically significant abnormalities or worsening from baseline were detected after enrollment, AEs were reported and patients were considered for further clinical investigation and/or expert consultation based on the investigator's medical judgment.

blood pressure and heart rate

Under standard conditions, blood pressure (BP) was measured in a seated position on the same arm at approximately the same time of day using the same device (after the patient had rested comfortably in the seated position for at least 5 min). Values are recorded in the e-CRF; systolic and diastolic blood pressures are recorded. At the first screening visit, measure BP in both arms. The arm with the highest diastolic blood pressure was determined at that visit and BP was measured on that arm throughout the study. This highest value is recorded in the e-CRF.

Measure heart rate while measuring BP.

weight and height

Weights are gained with the patient wearing underwear or very light clothing and no shoes and with an empty bladder. The same scale was used throughout the study.

Measure altitude, as self-reported altitude is not acceptable.

iTAQ Questionnaire

The iTAQ is a patient-reported outcome (PRO) measure to assess treatment acceptability over a 4-week period prior to questionnaire completion. Patients are asked to complete it at the Week 8 and Week 24 visits.

Insulin log

The patient was instructed to complete an insulin record with the aim of recording his/her daily insulin doses (basal and prandial insulin, if applicable) for at least 7 days prior to each visit and to carry this information to the next study visit. For more than 7 days prior to the study visit, patients could record daily insulin doses, but only information collected during the last 7 days prior to each visit was entered into the CRF.

result

A total of 76 patients with T1DM and 441 patients with T2DM were enrolled.

All 76 randomly assigned patients with T1DM were treated and therefore these patients were included in the safety population. Two randomly assigned patients with T1DM (both in the alirocumab arm) were excluded from the intention-to-treat (ITT) population.

Of the 441 T2DM patients, 3 were untreated (1 in the alirocumab group, 2 in the placebo group) and were therefore not included in the safety population. Twelve randomly assigned patients with T2DM (7 in the alirocumab group and 5 in the placebo group) were not included in the ITT population.

Patients were excluded from the ITT population if no calculated LDL-C value was available at baseline or within one of the analysis windows up to week 24.

study patients

Six (7.9%) patients with T1DM discontinued study treatment prematurely (3 [5.9%] in the alirixumab group (2 patients discontinued due to AEs) and 3 [12.0%] in the placebo group (2 patients discontinued due to AEs). All 3 patients in the alirocumab group also did not complete the study period, while in the placebo group, 2 patients also did not complete the study period, and 1 patient remained on study until the study period period completed.

Table 2: Management of patients with T1DM according to the IVRS

Percentages were calculated using the number of randomized patients as the denominator.

Thirty-nine (8.8%) patients with T2DM prematurely discontinued study treatment (29 (9.9%) in the alirocumab arm and 10 (6.8%) in the placebo arm. 29 patients in the alirocumab arm Of these, 18 patients also did not complete the study, and 11 patients remained on study until completion of the study period. In the placebo group, of 10 patients, 7 patients also did not complete the study period, and 3 patients remained on study until completion of the study period.

Table 3: Management of patients with T2DM according to the IVRS

Percentages were calculated using the number of randomized patients as the denominator.

Demographics and Baseline Characteristics

Baseline characteristics were generally similar in the alirixumab and placebo groups. 60.5% of randomly assigned patients with T1DM were male, while 54.2% of randomly assigned patients with T2DM were male. Patients with T1DM were younger with a mean age of 56.1 (SD=9.5), while those with T2DM were 64.0 (SD=9.1). Patients with T1DM had a mean BMI of 30.0 kg/m ² (SD=5.9), while patients with T2DM were observed to have a mean BMI of 32.6 kg/m ² (SD=5.06).

Table 4: Demographics and Patient Characteristics at Baseline - Patients with Type 1 Diabetes According to IVRS

BMI: body mass index.

Table 5: Demographics and Patient Characteristics at Baseline - Patients with Type 2 Diabetes According to IVRS

BMI: body mass index.

Baseline calculated LDL-C was higher in patients with T1DM (mean=121.0 mg/dL, SD=51.2) than in patients with T2DM (mean=110.4 mg/dL, SD=37.3). Patients with T1DM had median triglycerides at baseline (Q1:Q3) = 102.0 mg/dL (76.5: 135.0) lower than those with T2DM (Q1:Q3) = 147.0 mg/dL (105.0:212.0).

Table 6: Lipid Parameters at Baseline - Quantitative Summary in Conventional Units - Patients with Type 1 Diabetes According to IVRS

Regarding other lipid parameters, T1DM patients showed a percentage reduction from baseline in LDL-C particle number (LS mean) of 40.7% at week 12 and 44.4% at week 24, as well as a percentage of LDL-C particle size The reduction was 2.3% at week 12 and 2.3% at week 24. ApoC3 in these patients decreased by 6.9% at week 12 and 7.5% at week 24.

Table 7: Lipid parameters at baseline - quantitative summary in conventional units - in patients with type 2 diabetes mellitus according to the IVRS

Regarding other lipid parameters, T2DM patients showed a percentage reduction from baseline in LDL-C particle number (LS mean) of 37.6% at week 12 and 38.3% at week 24, as well as a percentage of LDL-C particle size The reduction was 2.6% at week 12 and 2.8% at week 24. ApoC3 in these patients decreased by 6.3% at week 12 and 5.8% at week 24.

In patients with T1DM, the mean duration of diabetes and the mean duration of insulin use were similar between treatment groups. The average duration of diabetes was 34.92 years (SD=12.67), and the average duration of insulin use was 34.81 years (SD=12.77). In patients with T2DM, the mean duration of diabetes and the mean duration of insulin use were similar between treatment groups. In T2DM, the mean duration of diabetes was 16.75 years (SD=8.13), and the mean duration of insulin use was 8.01 years (SD=6.90).

The duration of hypercholesterolemia was generally similar between treatment groups and between patients with T1DM and T2DM.

As reported by the investigators, the proportion of patients with statin intolerance was 31.6% in patients with T1DM and 23.8% in patients with T2DM.

The proportion of patients who received fibric acid at randomization was 2.6% of those with T1DM and 8.8% of those with T2DM.

The proportion of patients receiving cholesterol absorption inhibitors (including ezetimibe) at randomization was higher in the alirocumab group (13.6%) than in the placebo group (7.6%), particularly in patients with T2DM: 45 patients (15.3%) versus 10 patients (6.8%).

Cardiovascular history and risk factors were generally similar between treatment groups. The following differences were observed between patients with T1DM and those with T2DM:

(1) ASCVD was more frequent in patients with T2DM than in patients with T1DM (40.1% vs. 21.1%), as were coronary heart disease (34.7% vs. 15.8%) and stroke (8.2% vs. 2.6%) Higher, while the frequency of PAD was lower in T2DM vs. T1DM patients (4.3% vs. 9.2%).

(2) Among patients without ASCVD, 56.7% of patients with T1DM had target organ damage (microalbuminuria, macroalbuminuria) and/or CKD and / or retinopathy. Still in patients without ASCVD, the following additional cardiovascular risk factors were observed:

(a) T1DM patients were more frequent than T2DM patients: current smokers (20.0% vs. 14.0%), preproliferative diabetic retinopathy (36.7% vs. 12.9%), and proliferative diabetic retinopathy (20.0% vs. 5.7%).

(b) T1DM patients had lower frequencies than T2DM patients: hypertension (55.0% vs. 84.8%), microalbuminuria (10.0% vs. 19.7%), and low HDL-C (16.7% vs. 28.0%).

(3) Three or more CV risk factors were observed in patients without ASCVD in 45% of T1DM patients and 55.7% of T2DM patients.

Overall, patients with T1DM and T2DM were treated with high-intensity and moderate-intensity statins in both treatment groups, with a higher proportion of patients treated with moderate-intensity statins (58.9%). Overall, 59.0% of T1DM and T2DM patients received statin therapy alone.

Table 9: Background Lipid Modification Treatment at Randomization

Notes:

^aOnly for patients currently taking statins.

^bWith or without statins.

^c High-intensity statins equivalent to atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily or simvastatin 80 mg daily.

Moderate-intensity statins equivalent to atorvastatin 10 to 20 mg daily or rosuvastatin 5 to 10 mg daily or simvastatin 20 to 40 mg daily or pravastatin 40 to 80 mg daily or Lovastatin 40 mg or fluvastatin 80 mg daily or pitavastatin 2 to 4 mg daily.

Low-intensity statins are equivalent to simvastatin 10 mg daily or pravastatin 10 to 20 mg daily or lovastatin 20 mg daily or fluvastatin 20 to 40 mg daily or pitavastatin 1 mg daily.

Patients receiving more than one intensity level of statins were counted at the highest intensity level.

In addition to each strength of statin (where % is calculated using the number of patients taking the statin as the denominator) and each daily dose category (where % is calculated using the number of patients taking that particular statin as the denominator) , to calculate % using the number of randomized patients as the denominator.

The safety population exposures to the study drug product are summarized in Table 10.

Table 10: Exposure to Study Drug Product - Injection

Notes:

^aPatients titrated up at week 12 according to IVRS and then transacted with at least one injection of 150 mg alirocumab. Denominator corresponds to patients treated with IVRS after week 12 with at least one injection.

Patients were considered in the treatment group they actually received.

The duration of IMP injection exposure in weeks was defined as: (date of last IMP injection + 14 days - date of first IMP injection)/7, regardless of intermittent discontinuation.

effect

primary efficacy endpoint

In the ITT population of patients with T1DM and patients with T2DM, alirixumab was superior to placebo for the percent change in calculated LDL-C from baseline to week 24 (as shown in Tables 11 and 12 and Figure 2 and 3). In T1DM patients, the proportion of individuals who achieved LDL-C<70mg/dL (<1.8mmol/L) was 70.2% in the alicurumab group and 5.1% in the placebo group (P<0.0001). The proportion of individuals with C<50 mg/dL (1.3 mmol/L) was 55.1% in the alirocumab group and 0% in the placebo group (P value not calculable). In T2DM patients, the proportion of individuals who achieved LDL-C<70mg/dL (<1.8mmol/L) was 76.4% in the alicurumab group and 7.4% in the placebo group (P<0.0001), reaching The proportion of individuals with LDL-C <50 mg/dL (1.3 mmol/L) was 50.7% in the alirocumab group and 2.4% in the placebo group (P<0.0001). Sensitivity analyzes for the primary efficacy endpoint showed similar results in both populations (data not shown).

Table 11: Percent Change in Calculated LDL-C from Baseline to Week 24: MMRM - Patients with Type 1 Diabetes According to IVRS

Notes:

Least squares (LS) means, standard errors (SE) and p-values were obtained from MMRM (mixed effects model with repeated measures) analysis.

The model included fixed categorical effects for treatment group, randomization strata according to the IVRS, time point, interaction between treatment group and time point, interaction between stratum and time point, treatment group and strata Continuous fixed covariates for the interaction, the interaction of treatment group and stratum and time point, and the calculated LDL-C value at baseline and the interaction of baseline value and time point.

The MMRM model was performed on all patients in the ITT population (ie type 1 and type 2 diabetic patients).

The MMRM model and baseline descriptions were performed on patients using baseline values and post-baseline values in at least one analysis window used in the model.

p-values are followed by a '*' if statistically significant according to the fixed stratification method used to ensure robust control of the overall type I error rate at the 0.05 level.

Table 12: Percent Change in Calculated LDL-C from Baseline to Week 24: MMRM - Patients with Type 2 Diabetes According to IVRS

Notes:

Least squares (LS) means, standard errors (SE) and p-values were obtained from MMRM (mixed effects model with repeated measures) analysis.

The model included fixed categorical effects for treatment group, randomization stratum according to IVRS, time point, and interaction of treatment group with time point, stratum with time point, treatment group with stratum Continuous fixed covariates for the interaction, and the interaction of treatment group and stratum and time point, and the calculated LDL-C value at baseline and the interaction of baseline value and time point.

The MMRM model was performed on all patients in the ITT population (ie type 1 and type 2 diabetic patients).

MMRM models and baseline descriptions were performed on patients using baseline values and post-baseline values in at least one analysis window used in the model.

p-values are followed by a '*' if statistically significant according to the fixed stratification method used to ensure robust control of the overall type I error rate at the 0.05 level.

Secondary Efficacy Endpoints

Alirocumab resulted in significant reductions in non-HDL-C, ApoB, total cholesterol, and Lp(a) levels from baseline to week 24 (difference from placebo), as well as in patients with T1DM and in patients with T2DM The increase of HDL-C in the ITT population of the group (respectively shown in table 13 and 14).

Table 13: Percent Change from Baseline for Key Secondary Efficacy Endpoints - Patients with Type 1 Diabetes Mellitus

^† Stratified testing was terminated at the endpoint triglycerides in participants with T2D and HDL-C in participants with T1D, so all subsequent statistical comparisons were not considered statistically significant.

‡ P values are for descriptive purposes only.

Apo, apolipoprotein; ITT, intention-to-treat; LDL-C, low-density lipoprotein cholesterol; Lp(a), lipoprotein(a); LS, least squares; non-HDL-C, non-high-density lipoprotein cholesterol; TRL-C, triglyceride-rich lipoprotein cholesterol; SE, standard error; SD, standard deviation.

Table 14: Percent Change from Baseline for Key Secondary Efficacy Endpoints - Patients with Type 2 Diabetes

^† Stratified testing was terminated at the endpoint triglycerides in participants with T2D and HDL-C in participants with T1D, so all subsequent statistical comparisons were not considered statistically significant.

‡ P values are for descriptive purposes only.

Apo, apolipoprotein; ITT, intention-to-treat; LDL-C, low-density lipoprotein cholesterol; Lp(a), lipoprotein(a); LS, least squares; non-HDL-C, non-high-density lipoprotein cholesterol; TRL-C, triglyceride-rich lipoprotein cholesterol; SE, standard error; SD, standard deviation.

Diabetes-Related Endpoints

Overall, FPG and HbA1c and glucose-lowering treatment remained stable over time in both treatment groups in patients with T1DM and in patients with T2DM.

Regarding HbA1c, in the T1DM cohort, the mean HbA1c% was 7.84% (SD=0.94) at baseline in the alirocumab group, mean absolute change=-0.03% (0.6), while in the placebo group, Mean HbA1c was 7.68% (0.78) from baseline, mean absolute change = -0.23% (0.36). In the T2DM cohort, mean HbA1c was 7.52% (0.96) from baseline in the alirocumab arm, mean absolute change = 0.18% (0.74), and mean HbA1c was 7.54% from baseline in the placebo arm (1.02), mean absolute change = 0.06% (0.66).

Regarding FPG, in the T1DM cohort, the mean FPG was 173 mg/dL (SD=70.6) at baseline in the alirocumab group, mean absolute change = -0.03 mg/dL (0.6), while in the In the placebo group, mean FPG was 166.5 mg/dL (75.6) from baseline, mean absolute change = 14.6 mg/dL (75.9). In the T2DM cohort, mean FPG was 154.1 mg/dL (50.1) from baseline in the alirocumab arm, mean absolute change = 9.5 mg/dL (61.8) compared to baseline in the placebo arm 153.5mg/dL (52.5) at the place, mean absolute change=10.0mg/dL (47.0).

safety

A total of 344 patients (51 T1DM and 293 T2DM) were exposed to alirixumab and 170 patients (25 T1DM and 145 T2DM) were exposed to placebo.

Overall, the rate of patients with any treatment-emergent adverse event (TEAE) was similar across treatment groups in the safety population of patients with T1DM or T2DM (see Table 15).

Table 15: Summary of Adverse Event Profiles: Treatment-emergent adverse events

Notes:

TEAE: treatment emergent adverse event; SAE: serious adverse event.

n (%) = number and percentage of patients with at least one TEAE.

10%)地在以下系統器官分類(SOC)中報 告： TEAE higher frequency (

10%) are reported in the following System Organ Classes (SOC):

(a) Infectious diseases and infections (21.8% in alirixumab vs. 21.8% in placebo);

(b) gastrointestinal disorders (13.1% in alirocumab vs. 12.4% in placebo);

(c) musculoskeletal and connective tissue disorders (21.5% in alirocumab versus 15.9% in placebo); and

(d) Systemic disease and site of administration status (11.0% in alirixumab vs. 8.8% in placebo).

0.5%的發生率差異的TEAE(

2%)是(以阿利庫單抗組中頻率降低的順序)：肌痛(4.4%相對1.8%)，關節痛(2.9%相對1.8%)，支氣管炎(2.6%相對0.6%)，頭暈(2.6%相對1.2%)和外周性水腫(2.0%相對0.6%)。相比之下，安慰劑組中最頻繁報告的並且與阿利庫單抗組相比具有

0.5%的發生率差異的TEAE(

2%)是：流感(2.3%相對2.9%)，肢體疼痛(1.7%相對2.9%)，低血糖症(1.7%相對2.4%)，咳嗽(1.5%相對2.9%)，肌肉骨骼疼痛(1.2%相對2.4%)，上呼吸道感染(0.9%相對2.4%)，高血糖症(0.9%相對2.4%)，和肺炎(0.6%相對2.4%)。 At the PT level, the most frequently reported in the alirocumab group and had

TEAEs with a 0.5% incidence difference (

2%) Yes (in order of decreasing frequency in the alirocumab group): myalgia (4.4% vs 1.8%), arthralgia (2.9% vs 1.8%), bronchitis (2.6% vs 0.6%), dizziness ( 2.6% versus 1.2%) and peripheral edema (2.0% versus 0.6%). In contrast, the most frequently reported in the placebo group and had

TEAEs with a 0.5% incidence difference (

2%) were: influenza (2.3% vs. 2.9%), pain in extremity (1.7% vs. 2.9%), hypoglycemia (1.7% vs. 2.4%), cough (1.5% vs. 2.9%), musculoskeletal pain (1.2% 2.4% vs. 2.4%), upper respiratory infection (0.9% vs. 2.4%), hyperglycemia (0.9% vs. 2.4%), and pneumonia (0.6% vs. 2.4%).

Overall, 25 patients (7.3%) in the alirocumab group and 14 patients (8.2%) in the placebo group reported treatment-emergent SAEs. The SAE (at PT level) reported in more than 1 patient in either treatment group was pneumonia (1 patient (0.3%) in the alirixumab group vs. 2 patients (1.2%) in the placebo group , foraminal stenosis (2 patients (0.6%) in the alirocumab group vs none in the placebo group), and urinary tract infection (2 patients (0.6%) vs none in the placebo group). One month after administration of the first IMP dose (Visit 3), one death due to myocardial infarction was reported in a patient with T2DM in the placebo group. Overall, 17 patients (4.9 %) and 4 patients (2.4%) in the placebo group experienced a TEAE leading to permanent treatment discontinuation. At the PT level, the number of patients with TEAEs leading to permanent treatment discontinuation The proportions were: headache (2 patients (0.6%) in the alirocumab group vs. none in the placebo group), cognitive impairment (2 patients (0.6%) vs. none), atopic dermatitis (2 patients (0.6%) versus no patients) and myalgia (3 patients (0.9%) versus 2 patients (1.2%)).

3xULN(如果基線ALT<ULN)或ALT

基線值的2倍(如果基線ALT

ULN)。相對安慰劑組的1名患者(0.6%)，在阿利庫單抗組的2名患者(0.6%)中報告了這些事件。 Regarding Adverse Events of Special Interest (AESI), an increase in ALT meeting AESI criteria was defined as ALT

3xULN (if baseline ALT<ULN) or ALT

2 times the baseline value (if the baseline ALT

ULN). These events were reported in 2 patients (0.6%) in the alirixumab group versus 1 patient (0.6%) in the placebo group.

Anaphylactic drug reactions meeting AESI criteria were defined as anaphylaxis events that required consultation with another physician for further evaluation. These events were reported in 5 patients (1.5%) in the alirixumab group versus 4 patients (2.4%) in the placebo group. These reactions were mainly skin and subcutaneous tissue disorders in 3 patients (0.9%) in the alirixumab group (1 atopic dermatitis, 1 eczema, and 1 photosensitivity reaction) and 2 in the placebo group reported in patients (1.2%) (1 dermatitis, 1 drug rash). Two other AESI allergic drug reactions in the alirocumab group were drug hypersensitivity and eosinophilia.

Neurological events meeting AESI criteria were defined as those requiring additional investigations/procedures and/or referral to a specialist. Such an event was reported in 1 patient (0.3%) in the alikumab group (paresthesias) versus 1 patient (dysphagia) (0.6%) in the placebo group. Both events were reported in T2DM patients.

All neurocognitive events were considered AESI. Neurocognitive events according to sponsor or FDA group were reported in 4 patients (1.2%) in the alirocumab group compared with no patients in the placebo group. All events were reported in T2DM patients: cognitive impairment was reported in 2 patients (0.6%) and memory impairment and amnesia in 1 patient each (0.3%). Of note, 2 cognitive impairments also led to permanent treatment discontinuation.

Local injection site reactions meeting AESI criteria were defined as allergic local injection site reactions requiring another physician's consultation, or as clinically significant nonallergic local injection site reactions (eg, diameter >2.5 cm reactions of swelling or erythema; reactions that interfere with activity). Each investigator-confirmed LISR associated with IMP ('eCRF') was reported in 6 patients (1.7%) in the alirocumab group versus 8 patients (4.7%) in the placebo group (placebo versus Injection site reactions to alirixumab). No local injection site reactions (LISRs) meeting AESI criteria, defined as reactions requiring consultation with another physician for further evaluation, were reported.

There were no reports of symptomatic overdose or pregnancy.

10ULN)。所有患者均患有T2DM。沒有報告CPK增加>10 ULN。 Analysis of liver function tests (ALT, AST, ALP, total bilirubin), CPK and renal function tests (creatinine, eGFR, BUN) did not reveal differences over time in any of the study parameters between treatment groups. During the study period, PCSA analysis did not identify PCSA with increased ALT in any treatment group. Among patients with normal CPK values at baseline, an increase of >3 ULN was reported in 7 patients (2.1%) in the alirocumab group versus 1 patient (0.6%) in the placebo group (and

10ULN). All patients had T2DM. No CPK increases >10 ULN were reported.

30%且<100%)。沒有患者血肌酐增加>=100%。在腎功能方面沒有有意義的差異。 Regardless of baseline status, small differences in numerical values were observed in the proportion of patients with mild, moderate or severe reductions in glomerular filtration rate (GFR) during treatment: mild, moderate and severe reductions in GFR in Alicu These were 49.7%, 28.1%, and 3.8% of patients in the mAb group, and 50.6%, 24.4%, and 3.6% of patients in the placebo group. Similarly, an increase in serum creatinine was measured in 13 patients (3.8%) in the alirocumab group relative to 5 patients (3.0%) in the placebo group (

30% and <100%). No patient had an increase in serum creatinine >= 100%. There were no meaningful differences in renal function.

No meaningful differences in vital signs were observed between treatment groups.

Example 3: Analysis of Individuals with Type 2 Diabetes and ASCVD from the Odyssey DM-Insulin Clinical Trial

Individuals with diabetes typically have high levels of atherogenic lipoproteins and cholesterol consisting of low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (ApoB) and low-density lipoprotein particle number (LDL-PN) reflected. The presence of atherosclerotic cardiovascular disease (ASCVD) increases the risk of future cardiovascular events.

In this analysis, we assessed the efficacy and safety of alirocumab in individuals with T2DM, high LDL-C, or non-HDL-C, and identified patients receiving maximally tolerated statins in the DM-insulin study. Class ASCVD. DM-insulin study participants with ASCVD and T1DM were not included in this analysis because of the low number of individuals in this group (alirocumab: n=11; placebo: n=5). As used in this example, ASCVD is defined as coronary heart disease (CHD; acute and asymptomatic myocardial infarction (MI) and unstable angina), ischemic stroke or peripheral arterial disease.

Baseline and efficacy data were analyzed according to the study. Efficacy analyzes included percent reduction from baseline at week 24 for non-HDL-C, LDL-C, ApoB, and LDL-PN, and achieving non-HDL-C <100 mg/dL (<2.59 mmol/L), LDL-C at week 24 -C<70mg/dL (<1.81mmol/L) and the percentage of individuals with ApoB<80 mg/dL. The intention-to-treat (ITT) analysis included all randomly assigned individuals with baseline LDL-C values and at least one LDL-C value through Week 24.

The analysis included 177 DM-insulin individuals with established ASCVD and T2DM (Table 16).

Table 16: Baseline characteristics (randomly assigned population)

^† Diagnosis by invasive/noninvasive testing. ^‡ Includes patients with established HTN on anti-HTN drug therapy. ^§Defined as an estimated glomerular filtration rate of 15-60 mL/min/1.73m ² . ^| Defined as microalbuminuria, macroalbuminuria, retinopathy, and/or CKD. ^¶One individual in the placebo group was not receiving insulin at randomization and

Remain without insulin therapy.

BMI, body mass index; DPP4, dipeptidyl peptidase 4; GLP-1, glucagon-like peptide 1; GLT, glucose-lowering therapy; FPG, fasting plasma glucose, HbA1c, glycated hemoglobin; HTN, hypertension; SGLT2, sodium /glucose cotransporter 2.

Regardless of treatment assignment, 89.3% of the analyzed individuals had a history of hypertension and 28.2% had chronic kidney disease (CKD) in addition to ASCVD. In total, 20.3% had a confirmed history of ischemic stroke and 10.7% had peripheral arterial disease (PAD). Regardless of treatment assignment, at baseline, mean (standard deviation [SD]) non-HDL-C levels were 144.2 (46.2) mg/dL [3.73 (1.20) mmol/L]; mean LDL-C levels were 108.7 (39.1) mg/dL [2.82 (1.01) mmol/L].

effect

Relative to controls, alirocumab reduced non-HDL-C, ApoB, LDL-PN, and LDL-C from baseline at week 24 (Figure 4). At week 24, a significantly higher proportion of individuals achieved non-HDL-C <100 mg/dL (<2.59 mmol/L), LDL-C <70 mg/dL (<1.81 mmol/L) and ApoB <80 mg compared to controls /dL (all P<0.0001; Figure 5).

safety

Individuals with T2DM, high LDL-C or non-HDL-C and established ASCVD receiving a maximally tolerated statin in the DM-Insulin study and a maximally tolerated statin in the DM-Dyslipidemia study Safety analyzes were performed in a pooled cohort of individuals with T1DM or T2DM, high LD-C or non-HDL-C, and established ASCVD (see Chan et al. (2017) Ann Transl Med. 5(23): 477 , which is incorporated herein by reference in its entirety). In total, 66.4% (alirocumab) and 67.0% (control) of individuals reported treatment-emergent adverse events (TEAEs; Table 17). Adverse event patterns were similar in the two groups. Each treatment group at baseline (alirocumab: 7.3 [0.9]%; control group: 7.3 [0.9]%) and week 24 (alirocumab: 7.6 [1.2]%; control group: 7.5 [1.2]% ]%; safety analysis) HbA1c mean (SD) levels were similar. regardless of treatment assignment How, at baseline (alirocumab: 154.2 [47.9] mg/dL, 8.6 [2.7] mmol/L; control group: 149.5 [43.7] mg/dL, 8.3 [2.4] mmol/L) and at week 24 ( Alicumab: 164.7 [54.9] mg/dL, 9.1 [3.0] mmol/L; control group: 159.4 [48.4] mg/dL, 8.9 [2.7] mmol/L; safety analysis) FPG levels were also similar .

Table 17: Safety Summary

SAE, serious adverse event.

in conclusion

In individuals with T2DM and ASCVD who had high LDL-C levels despite maximally tolerated statin use, alirocumab significantly reduced levels of atherogenic cholesterol and LDL-PN relative to controls.

Claims (28)

A 75mg, 150mg or 300mg antibody specifically binding to human proprotein convertase subtilisin/kexin type 9 (PCSK9) or an antigen-binding fragment thereof is used for the preparation of a drug for treating hypercholesterolemia in a patient in need, wherein the patient is a high cardiovascular risk patient receiving insulin therapy, the patient has (i) type 1 diabetes mellitus (T1DM), and (ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and The patient received concomitant insulin therapy. The use according to claim 1, wherein 75 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. The use according to claim 1, wherein 150 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. The use according to claim 1, wherein 300 mg of the antibody or antigen-binding fragment is administered to the patient every four weeks. The use as in any one of the preceding claims, wherein the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs shown in SEQ ID NO: 2, 3 and 4, and the three heavy chain CDRs shown in SEQ ID NO: 7, 8 and 10 Three light chain CDRs are shown. The use as in any one of the preceding claims, wherein the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 1, and an amine having the amino acid sequence of SEQ ID NO: 6 The amino acid sequence of the light chain variable region (LCVR). The use according to any one of the preceding claims, wherein the antibody or antigen-binding fragment thereof is selected from the group consisting of: alikizumab, evolocizumab, bococizumab, rodhizumab, ralpancizumab and LY3015014. The use according to claim 7, wherein the antibody or antigen-binding fragment thereof is alicumab. The use of any one of the preceding claims, wherein: One or more doses of 75 mg of the antibody or antigen-binding fragment thereof are administered to the patient about every two weeks if the LDL-C level in the patient is below a threshold level, or if the LDL-C level in the patient If the level is greater than or equal to the threshold level, one or more doses of 150 mg of the antibody or antigen-binding fragment thereof are administered about every two weeks. The use of any one of the preceding claims, wherein: One or more doses of 300 mg of the antibody or antigen-binding fragment thereof are administered to the patient about every four weeks if the LDL-C level in the patient is below a threshold level, or if the LDL-C level in the patient is greater than or equal to For this threshold level, one or more doses of 150 mg of the antibody or antigen-binding fragment thereof are administered approximately every two weeks. The use according to claim 9 or 10, wherein the threshold level is 70 mg/dL. The use according to any one of the preceding claims, wherein the antibody or antigen-binding fragment thereof is administered subcutaneously. The use according to any one of the preceding claims, wherein the patient further receives concomitant lipid modification therapy (LMT). The use according to claim 13, wherein the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrous acids, niacin, omega-3 fatty acids and bile acid sequestrants. The use according to claim 14, wherein the LMT is statin therapy. The use as claimed in item 15, wherein the statins are selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin and sivastatin Rivastatin. The use according to any one of claims 14-16, wherein the statin therapy is a maximally tolerated statin therapy. The use according to claim 14, wherein the cholesterol absorption inhibitor is ezetimibe. The use according to any one of claims 1-14 and 18, wherein the patient is intolerant to statins. Use as in any one of the preceding claims, wherein the insulin treatment is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart and Basal insulin. Use as in any one of the preceding claims, wherein the patient receives concomitant antidiabetic therapy in addition to insulin therapy. The use according to claim 21, wherein the additional concomitant anti-diabetic treatment is selected from the group consisting of: glucagon-like peptide 1 (GLP-1) treatment, gastrointestinal peptide, glucagon receptor agonist Glucose-dependent insulinotropic polypeptide (GIP) receptor agonists or antagonists, growth hormone releasing hormone antagonists or inverse agonists, xenin, xenin analogs, biguanides, sulfonylureas, Meglitinides, thiazolidinediones, DPP-4 inhibitors, alpha-glucosidase inhibitors, sodium-dependent glucose transporter 2 (SGLT-2) inhibitors, SGLT-1 inhibitors, peroxides Proliferator-activated receptor (PPAR-) (alpha, gamma, or alpha/gamma) agonists or modulators, amylin, amylin analogs, G protein-coupled receptor 119 (GPR119) agonists , GPR40 agonists, GPR120 agonists, GPR142 agonists, systemic or poorly absorbed TGR5 agonists, diabetes immunotherapy, anti-inflammatory agents for the treatment of metabolic syndrome and diabetes, adenosine monophosphate-activated protein Kinase (AMPK) stimulator, inhibitor of 11-β-hydroxysteroid dehydrogenase 1, activator of glucokinase, inhibitor of diacylglycerol O-acyltransferase (DGAT), glucose transporter-4 modulators, somatostatin receptor 3 agonists, lipid-lowering agents, and combinations thereof. The use according to any one of the preceding claims, wherein the antibody or antigen-binding fragment thereof lowers the patient's LDL-C level by at least 40%. The use according to any one of the preceding claims, wherein the antibody or antigen-binding fragment thereof reduces the patient's non-HDL-C levels by at least 35%. The use according to any one of the preceding claims, wherein the antibody or antigen-binding fragment thereof reduces the patient's apolipoprotein C3 (ApoC3) level. The use according to any one of the preceding claims, wherein the antibody or antigen-binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient. The use according to any one of the preceding claims, wherein the antibody or antigen-binding fragment thereof: (a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or (b) Does not affect the patient's fasting plasma glucose (FPG) level. A 75 mg antibody specifically binding to human proprotein convertase subtilisin/kexin type 9 (PCSK9) or an antigen-binding fragment thereof is used for the preparation of a medicament for treating hypercholesterolemia in a patient in need: wherein the patient is a high cardiovascular risk patient receiving insulin therapy, the patient has (i) type 1 diabetes mellitus (T1DM), and (ii) hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and wherein the antibody or antigen-binding fragment thereof is administered to the patient every two weeks; and One or more doses of 75 mg of the antibody or antigen-binding fragment thereof are administered to the patient about every two weeks if the LDL-C level in the patient is less than 70 mg/dL, or if the LDL-C level in the patient is greater than or equal to 70 mg/dL, administer one or more doses of 150 mg of the antibody or antigen-binding fragment thereof approximately every two weeks, wherein the antibody or antigen-binding fragment thereof comprises HCVR having the amino acid sequence of SEQ ID NO: 1 and LCVR having the amino acid sequence of SEQ ID NO: 6, and wherein the patient is receiving concomitant insulin therapy.

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