US20110123543A1

US20110123543A1 - TNFalpha antagonists and methotrexate in the treatment of TNF-mediated disease

Info

Publication number: US20110123543A1
Application number: US12/583,851
Authority: US
Inventors: Marc Feldmann; Ravinder N. Maini
Original assignee: Kennedy Institute of Rheumotology
Current assignee: Kennedy Trust for Rheumatology Research
Priority date: 1992-10-08
Filing date: 2009-08-26
Publication date: 2011-05-26
Also published as: US20120141474A1; EP0914157B1; EP1593393A3; EP1593393B1; HK1020011A1; ES2247635T3; LU92098I2; ATE535255T1; US20090175859A1; CA2261630A1; LU92004I2; EP0914157A1; US6270766B1; EP1941904A3; AU719015B2; US20120141475A1; PT1941904E; LU92099I2; US8383120B2; EP1941904A2

Abstract

Methods for treating and/or preventing a TNF-mediated disease in an individual are disclosed. Also disclosed is a composition comprising methotrexate and an anti-tumor necrosis factor antibody. TNF-mediated diseases include rheumatoid arthritis, Crohn's disease, and acute and chronic immune diseases associated with transplantation.

Description

RELATED APPLICATIONS

This application is a continuation of U.S. Ser. No. 11/225,631, filed Sep. 12, 2005, which is a continuation of U.S. Ser. No. 09/754,004, filed Jan. 3, 2001, now abandoned, which is a continuation of U.S. Ser. No. 08/690,775, filed Aug. 1, 1996, now U.S. Pat. No. 6,270,766 B1, issued Aug. 7, 2001, which (1) is a continuation-in-part of U.S. Ser. No. 08/607,419, filed Feb. 28, 1996, which is a continuation-in-part of International Application No. PCT/GB94/00462, filed Mar. 10, 1994, and (2) is a continuation-in-part of U.S. Ser. No. 08/403,785, filed May 3, 1995, now U.S. Pat. No. 5,741,488, issued Apr. 21, 1998, which is the U.S. National Phase of International Application No. PCT/GB93/02070, filed Oct. 6, 1993, which is a continuation-in-part of U.S. Ser. No. 07/958,248, filed Oct. 8, 1992, now abandoned, the entire teachings of all of which are incorporated herein by reference.

BACKGROUND OF THE INVENTION

Monocytes and macrophages secrete cytokines known as tumor necrosis factor alpha (TNFOα) and tumor necrosis factor beta (TNFβ) in response to endotoxin or other stimuli. TNFα is a soluble homotrimer of 17 kD protein subunits (Smith et al., J. Biol. Chem. 262:6951-6954 (1987)). A membrane-bound 26 kD precursor form of TNF also exists (Kriegler et al., Cell 53:45-53 (1988)). For reviews of TNF, see Beutler et al., Nature 320:584 (1986); Old, Science 230:630 (1986); and Le et al., Lab. Invest. 56:234 (1987).
Cells other than monocytes or macrophages also produce TNFα. For example, human non-monocytic tumor cell lines produce tumor necrosis factor (TNF) (Rubin et al., J. Exp. Med. 164:1350 (1986); Spriggs et al., Proc. Natl. Acad. Sci. USA 84:6563 (1987)). CD4+ and CD8+ peripheral blood T lymphocytes and some cultured T and B cell lines (Cuturi et al., J. Exp. Med. 165:1581 (1987); Sung et al., J. Exp. Med. 168:1539 (1988); Turner et al., Eur. J. Immunol. 17:1807-1814 (1987)) also produce TNFα.
TNF causes pro-inflammatory actions which result in tissue injury, such as degradation of cartilage and bone, induction of adhesion molecules, inducing procoagulant activity on vascular endothelial cells (Pober et al., J. Immunol. 136:1680 (1986)), increasing the adherence of neutrophils and lymphocytes (Pober et al., J. Immunol. 138:3319 (1987)), and stimulating the release of platelet activating factor from macrophages, neutrophils and vascular endothelial cells (Camussi et al., J. Exp. Med. 166:1390 (1987)).
Recent evidence associates TNF with infections (Cerami et al., Immunol. Today 9:28 (1988)), immune disorders, neoplastic pathologies (Oliff et al., Cell 50:555 (1987)), autoimmune pathologies and graft-versus-host pathologies (Piquet et al., J. Exp. Med. 166:1280 (1987)). The association of TNF with cancer and infectious pathologies is often related to the host's catabolic state. Cancer patients suffer from weight loss, usually associated with anorexia.
The extensive wasting which is associated with cancer, and other diseases, is known as “cachexia” (Kern et al., J. Parent. Enter. Nutr. 12:286-298 (1988)). Cachexia includes progressive weight loss, anorexia, and persistent erosion of body mass in response to a malignant growth. The fundamental physiological derangement can relate to a decline in food intake relative to energy expenditure. The cachectic state causes most cancer morbidity and mortality. TNF can mediate cachexia in cancer, infectious pathology, and other catabolic states.
TNF also plays a central role in gram-negative sepsis and endotoxic shock (Michie et al., Br. J. Surg. 76:670-671 (1989); Debets et al., Second Vienna Shock Forum, p. 463-466 (1989); Simpson et al., Crit. Care Clin. 5:27-47 (1989)), including fever, malaise, anorexia, and cachexia. Endotoxin strongly activates monocytelmacrophage production and secretion of TNF and other cytokines (Kornbluth et al., J. Immunol. 137:2585-2591 (1986)). TNF and other monocyte-derived cytokines mediate the metabolic and neurohormonal responses to endotoxin (Michie et al., New Engl. J. Med. 318:1481-1486 (1988)). Endotoxin administration to human volunteers produces acute illness with flu-like symptoms including fever, tachycardia, increased metabolic rate and stress hormone release (Revhaug et al., Arch. Surg. 123:162-170 (1988)). Circulating TNF increases in patients suffering from Gram-negative sepsis (Waage et al., Lancet 1:355-357 (1987); Hammerle et al., Second Vienna Shock Forum p. 715-718 (1989); Debets et al., Crit. Care Med. 17:489-497 (1989); Calandra et al., J. Infect. Dis. 161:982-987 (1990)).
Thus, TNFα has been implicated in inflammatory diseases, autoimmune diseases, viral, bacterial and parasitic infections, malignancies, and/or neurogenerative diseases and is a useful target for specific biological therapy in diseases, such as rheumatoid arthritis and Crohn's disease. Beneficial effects in open-label trials with a chimeric monoclonal antibody to TNFα (cA2) have been reported with suppression of inflammation (Elliott et al., Arthritis Rheum. 36:1681-1690 (1993); Elliott et al., Lancet 344:1125-1127 (1994)). See also, Van Dullemen et al., Gastroenterology 109:129-135 (1995). Beneficial results in a randomized, double-blind, placebo-controlled trial with cA2 have also been reported with suppression of inflammation (Elliott et al., Lancet 344:1105-1110 (1994)).

SUMMARY OF THE INVENTION

The present invention is based on the discovery that treatment of patients suffering from a TNF-mediated disease with a tumor necrosis factor antagonist, such as an anti-tumor necrosis factor antibody, as adjunctive and/or concomitant therapy to methotrexate therapy produces a rapid and sustained reduction in the clinical signs and symptoms of the disease. The present invention is also based on the unexpected and dramatic discovery that a multiple dose regimen of a tumor necrosis factor antagonist, such as an anti-tumor necrosis factor antibody, when administered adjunctively with methotrexate to an individual suffering from a TNF-mediated disease produces a highly beneficial or synergistic clinical response for a significantly longer duration compared to that obtained with a single or multiple dose regimen of the antagonist administered alone or that obtained with methotrexate administered alone. As a result of Applicants' invention, a method is provided herein for treating and/or preventing a TNF-mediated disease in an individual comprising co-administering an anti-TNF antibody or a fragment thereof and methotrexate to the individual in therapeutically effective amounts. In a particular embodiment, methotrexate is administered in the form of a series of low doses separated by intervals of days or weeks.
A method is also provided herein for treating and/or preventing recurrence of a TNF-mediated disease in an individual comprising co-administering an anti-TNF antibody or a fragment thereof and methotrexate to the individual in therapeutically effective amounts. TNF-mediated diseases include rheumatoid arthritis, Crohn's disease, and acute and chronic immune diseases associated with an allogenic transplantation (e.g., renal, cardiac, bone marrow, liver, pancreatic, small intestine, skin or lung transplantation).
Therefore, in one embodiment, the invention relates to a method of treating and/or preventing rheumatoid arthritis in an individual comprising co-administering an anti-TNF antibody or a fragment thereof and methotrexate to the individual in therapeutically effective amounts. In a second embodiment, the invention relates to a method of treating and/or preventing Crohn's disease in an individual comprising co-administering an anti-TNF antibody or a fragment thereof and methotrexate to the individual in therapeutically effective amounts. In a third embodiment, the invention relates to a method of treating and/or preventing other autoimmune diseases and/or acute or chronic immune disease associated with a transplantation in an individual, comprising co-administering an anti-TNF antibody or a fragment thereof and methotrexate to the individual in therapeutically effective amounts.
A further embodiment of the invention relates to compositions comprising an anti-TNF antibody or a fragment thereof and methotrexate.
In addition to anti-TNF antibodies, TNF antagonists include anti-TNF antibodies and receptor molecules which bind specifically to TNF; compounds which prevent and/or inhibit TNF synthesis, TNF release or its action on target cells, such as thalidomide, tenidap, phosphodiesterase inhibitors (e.g, pentoxifylline and rolipram), A2b adenosine receptor agonists and A2b adenosine receptor enhancers; and compounds which prevent and/or inhibit TNF receptor signalling.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A-1C are a set of three graphs showing the results over time for swollen joint count in rheumatoid arthritis (RA) patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph. White circle=−methotrexate (MTX−); black circle=+methotrexate (MTX+); square=placebo.

FIGS. 2A-2C are a set of three graphs showing the results over time for tender joint count in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph. White circle=−methotrexate; black circle=+methotrexate; square=placebo.

FIGS. 3A-3C are a set of three graphs showing the results over time for the Physician's Global Disease Assessment in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph. White circle=−methotrexate; black circle=+methotrexate; square=placebo.

FIGS. 4A-4C are a set of three graphs showing the results over time for the Patient Disease Assessment in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph. White circle=−methotrexate; black circle=+methotrexate; square=placebo.

FIGS. 5A-5C are a set of three graphs showing the results over time for C-reactive protein (CRP) concentration in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph. White circle=−methotrexate; black circle=+methotrexate; square=placebo.

FIGS. 6A-6C are a set of three graphs showing the results over time for the Health Assessment Questionnaire (HAQ) in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph. White circle=−methotrexate; black circle=+methotrexate; square=placebo.

FIGS. 7A-7F are a set of six graphs showing the serum cA2 concentration in each RA patient receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate, plotted over time. Data plotted are the serum cA2 concentrations obtained just before the administration of cA2 at

weeks

2, 6, 10 and 14 and then at

weeks

18 and 26. The scales for the serum cA2 concentration are condensed with higher doses of cA2.

FIGS. 8A and 8B are a set of two graphs showing the median serum cA2 concentration over time in RA patients receiving 3 mg/kg cA2 (top panel) or 10 mg/kg cA2 (bottom panel) with or without methotrexate. Square=+methotrexate; circle or triangle=−methotrexate.

FIG. 1 contains a set of graphs from an experiment which illustrates the suppression of arthritis as assessed by the clinical score (FIG. 1 a) and pawswelling measurements (FIG. 1 b) after the administration of 50 μg anti-TNF (hamster TN3.19.2) and 200 μg anti-CD4 to DBA/1 male mice.

FIG. 2 contains a set of graphs from a second experiment which illustrates the potentiation of low dose anti-TNF and anti-CD4 on clinical score (FIG. 2 a) and pawswelling measurements (FIG. 2 b) after administration of 50 μg anti-TNF 200 μg anti-CD4; and the clinical score (FIG. 2 c) and pawswelling measurements (FIG. 2 d) after administration of 300 μg anti-TNF with 200 μg anti-CD4, to DBA/1 male mice.

FIG. 3 is a graph illustrating the suppression of arthritis as assessed by pawswelling measurements after the administration of 250 μg cyclosporine A, 50 μg anti-TNF antibody, and a combination of 250 μg cyclosporine A and 50 μg anti-TNF antibody to DBA/1 mice. Open squares=control; diamonds=cyclosporine A; triangles=anti-TNF; closed squares=cyclosporine A/anti-TNF.

FIG. 6 is a graph showing the effect of administering 300 μg anti-TNF antibody alone, a combination of 250 μg cyclosporin A and 300 μg anti-TNF antibody to male DBA/1 mice on the suppression of arthritis as assessed by paw-swelling measurements. Open square=cyclosporin A plus anti-TNF antibody; diamond=cyclosporin A plus control antibody; triangle=anti-TNF antibody.

FIG. 7 is a graph showing the effect of administering 500 μg cyclosporine A alone, 250 μg anti-TNF antibody alone, and a combination of 500 μg cyclosporine A and 250 μg anti-TNF antibody to male DBA/1 mice on the suppression of arthritis as assessed by clinical score. Open square control; diamond =anti-TNF antibody; triangle=cyclosporine A; square=cyclosporine A plus anti-TNF antibody. P<0.05 (vs. PBS treated group)

FIGS. 9A and 9B are graphs showing results of a cross-blocking epitope ELISA with murine A2 (mA2) and chimeric (cA2) antibody competitors.

FIG. 10A and 10B are graphs of a Scatchard analysis of ¹²⁵I-labelled mAb A2 (mA2) and chimeric A2 (cA2) binding to recombinant human TNFα immobilized on a microtiter plate. Each Ka value was calculated from the average of two independent determinations.

FIG. 24 is a graphical representation of swollen joint counts (maximum 28), as recorded by a single observer. Circles represent individual patients and horizontal bars show median values at each time point. The screening time point was within 4 weeks of entry to the study (week 0); data from patient 15 were not included after week 2 (dropout). Significance of the changes, relative to week 0, by Mann Whitney test, adjusted: week 1, p>0.05; week 2, p<0.02; weeks 3-4, p<0.002; weeks 6-8, p>0.001.

FIG. 25 is a graphical representation of levels of serum C-reactive protein (CRP)-Serum CRP (normal range 0-10 mg/liter), measured by nephelometry. Circles represent individual patients and horizontal bars show median values at each time point. The screening time point was within 4 weeks of entry to the study (week 0); data from patient 15 were not included after week 2 (dropout). Significance of the changes, relative to week 0, by Mann-Whitney test, adjusted: week 1, p<0.001; week 2, p<0.003; week 3, p<0.002; week 4, p<0.02;

week

6,8, p<0.001.

DETAILED DESCRIPTION OF THE INVENTION

The present invention relates to the discovery that tumor necrosis factor antagonists can be administered to patients suffering from a TNF-mediated disease as adjunctive and/or concomitant therapy to methotrexate therapy, with good to excellent alleviation of the signs and symptoms of the disease. The present invention also relates to the discovery that tumor necrosis factor antagonists can be administered to patients suffering from a TNF-mediated disease in multiple doses and as adjunctive and/or concomitant therapy to methotrexate therapy, with a significant improvement in duration of clinical response.
As a result of Applicants' invention, a method is provided herein for treating and/or preventing a TNF-mediated disease in an individual, comprising co-administering methotrexate and a tumor necrosis factor antagonist to the individual in therapeutically effective amounts. The TNF antagonist and methotrexate can be administered simultaneously or sequentially. The TNF antagonist and methotrexate can each be administered in single or multiple doses. Multiple TNF antagonists can be co-administered with methotrexate. Other therapeutic regimens and agents can be used in combination with the therapeutic co-administration of TNF antagonists and methotrexate or other drugs that suppress the immune system.
A method is also provided herein for treating and/or preventing recurrence of a TNF-mediated disease in an individual comprising co-administering methotrexate and a TNF antagonist to the individual in therapeutically effective amounts.
As used herein, a “TNF-mediated disease” refers to a TNF related pathology or disease. TNF related pathologies or diseases include, but are not limited to, the following:

- (A) acute and chronic immune and autoimmune pathologies, such as, but not limited to, rheumatoid arthritis (RA), juvenile chronic arthritis (JCA), thyroiditis, graft versus host disease (GVHD), scleroderma, diabetes mellitus, Graves' disease, allergy, acute or chronic immune disease associated with an allogenic transplantation, such as, but not limited to, renal transplantation, cardiac transplantation, bone marrow transplantation, liver transplantation, pancreatic transplantation, small intestine transplantation, lung transplantation and skin transplantation;
- (B) infections, including, but not limited to, sepsis syndrome, cachexia, circulatory collapse and shock resulting from acute or chronic bacterial infection, acute and chronic parasitic and/or infectious diseases, bacterial, viral or fungal, such as a human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) (including symptoms of cachexia, autoimmune disorders, AIDS dementia complex and infections);
- (C) inflammatory diseases, such as chronic inflammatory pathologies, including chronic inflammatory pathologies such as, but not limited to, sarcoidosis, chronic inflammatory bowel disease, ulcerative colitis, and Crohn's pathology or disease; vascular inflammatory pathologies, such as, but not limited to, disseminated intravascular coagulation, atherosclerosis, Kawasaki's pathology and vasculitis syndromes, such as, but not limited to, polyarteritis nodosa, Wegener's granulomatosis, Henoch-Schonlein purpura, giant cell arthritis and microscopic vasculitis of the kidneys; chronic active hepatitis; Sjogren's syndrome; spondyloarthropathies, such as ankylosing spondylitis, psoriatic arthritis and spondylitis, enteropathic arthritis and spondylitis, reactive arthritis and arthritis associated with inflammatory bowel disease; and uveitis;
- (D) neurodegenerative diseases, including, but not limited to, demyelinating diseases, such as multiple sclerosis and acute transverse myelitis; myasthenia gravis; extrapyramidal and cerebellar disorders, such as lesions of the corticospinal system; disorders of the basal ganglia or cerebellar disorders; hyperkinetic movement disorders, such as Huntington's chorea and senile chorea; drug-induced movement disorders, such as those induced by drugs which block central nervous system (CNS) dopamine receptors; hypokinetic movement disorders, such as Parkinson's disease; progressive supranuclear palsy; cerebellar and spinocerebellar disorders, such as astructural lesions of the cerebellum; spinocerebellar degenerations (spinal ataxia, Friedreich's ataxia, cerebellar cortical degenerations, multiple systems degenerations (Mencel, Dejerine-Thomas, Shi-Drager, and MachadoJoseph)); and systemic disorders (Refsum's disease, abetalipoprotienemia, ataxia, telangiectasia, and mitochondrial multisystem disorder); disorders of the motor unit, such as neurogenic muscular atrophies (anterior horn cell degeneration, such as amyotrophic lateral sclerosis, infantile spinal muscular atrophy and juvenile spinal muscular atrophy); Alzheimer's disease; Down's syndrome in middle age; diffuse Lewy body disease; senile dementia of Lewy body type; Wernicke-Korsakoff syndrome; chronic alcoholism; primary biliary cirrhosis; cryptogenic fibrosing alveolitis and other fibrotic lung diseases; hemolytic anemia; Creutzfeldt-Jakob disease; subacute sclerosing panencephalitis, Hallervorden-Spatz disease; and dementia pugilistica, or any subset thereof;
- (E) malignant pathologies involving TNF-secreting tumors or other malignancies involving TNF, such as, but not limited to, leukemias (acute, chronic myelocytic, chronic lymphocytic and/or myelodyspastic syndrome); lymphomas (Hodgkin's and non-Hodgkin's lymphomas, such as malignant lymphomas (Burkitt's lymphoma or Mycosis fungoides));
- (F) cachectic syndromes and other pathologies and diseases involving excess TNF, such as, but not limited to, cachexia of cancer, parasitic disease and heart failure; and
- (G) alcohol-induced hepatitis and other forms of chronic hepatitis. See, e.g., Berkow et al., Eds., The Merck Manual, 16th edition, chapter 11, pp. 1380-1529, Merck and Co., Rahway, N.J., 1992, incorporated herein by reference.

The terms “recurrence”, “flare-up” or “relapse” are defined to encompass the reappearance of one or more symptoms of the disease state. For example, in the case of rheumatoid arthritis, a reoccurrence can include the experience of one or more of swollen joints, morning stiffness or joint tenderness.
In one embodiment, the invention relates to a method of treating and/or preventing rheumatoid arthritis in an individual comprising co-administering methotrexate and a TNF antagonist to the individual in therapeutically effective amounts.
In a second embodiment, the invention relates to a method for treating and/or preventing Crohn's disease in an individual comprising co-administering a methotrexate and a TNF antagonist to the individual in therapeutically effective amounts.
In a third embodiment, the invention relates to a method for treating and/or preventing an acute or chronic immune disease associated with an allogenic transplantation in an individual comprising co-administering methotrexate and a TNF antagonist to the individual in therapeutically effective amounts. As used herein, a “transplantation” includes organ, tissue or cell transplantation, such as renal transplantation, cardiac transplantation, bone marrow transplantation, liver transplantation, pancreatic transplantation, small intestine transplantation, skin transplantation and lung transplantation.
The benefits of combination therapy with methotrexate and TNF antagonists include high clinical response rates for significantly longer durations in comparison with that obtained with treatment with each therapeutic modality separately. In addition, methotrexate significantly reduces immunogenicity of anti-TNF antibodies, thus permitting administration of multiple dosages of anti-TNF antibodies with enhanced safety. The results described herein suggest that methotrexate can be used to reduce immunogenicity of other antibodies or proteins. Based on the results described herein, methotrexate can be used in other forms of antibody therapy, such as anti-IL-2 antibody therapy. This method is particularly pertinent in therapies other than anti-CD4 antibody therapy.
In a further embodiment, the invention relates to compositions comprising methotrexate and a TNF antagonist. The compositions of the present invention are useful for treating a subject having a pathology or condition associated with abnormal levels of a substance reactive with a TNF antagonist, in particular TNF in excess of, or less than, levels present in a normal healthy subject, where such excess or diminished levels occur in a systemic, localized or particular tissue type or location in the body. Such tissue types can include, but are not limited to, blood, lymph, central nervous system (CNS), liver, kidney, spleen, heart muscle or blood vessels, brain or spinal cord white matter or grey matter, cartilage, ligaments, tendons, lung, pancreas, ovary, testes, prostate. Increased or decreased TNF concentrations relative to normal levels can also be localized to specific regions or cells in the body, such as joints, nerve blood vessel junctions, bones, specific tendons or ligaments, or sites of infection, such as bacterial or viral infections.

Tumor Necrosis Factor Antagonists

As used herein, a “tumor necrosis factor antagonist” decreases, blocks, inhibits, abrogates or interferes with TNF activity in vivo. For example, a suitable TNF antagonist can bind TNF and includes anti-TNF antibodies and receptor molecules which bind specifically to TNF. A suitable TNF antagonist can also prevent or inhibit TNF synthesis and/or TNF release and includes compounds such as thalidomide, tenidap, and phosphodiesterase inhibitors, such as, but not limited to, pentoxifylline and rolipram. A suitable TNF antagonist that can prevent or inhibit TNF synthesis and/or TNF release also includes A2b adenosine receptor enhancers and A2b adenosine receptor agonists (e.g., 5′-(N-cyclopropyl)-carboxamidoadenosine, 5′-N-ethylcarboxamidoadenosine, cyclohexyladenosine and R-N.sup.6 -phenyl-2-propyladenosine). See, for example, Jacobson (GB 2 289 218 A), the teachings of which are entirely incorporated herein by reference. A suitable TNF antagonist can also prevent or inhibit TNF receptor signalling.

Anti-TNF Antibodies

As used herein, an “anti-tumor necrosis factor antibody” decreases, blocks, inhibits, abrogates or interferes with TNF activity in vivo. Anti-TNF antibodies useful in the methods and compositions of the present invention include monoclonal, chimeric, humanized, resurfaced and recombinant antibodies and fragments thereof which are characterized by high affinity binding to TNF and low toxicity (including human anti-murine antibody (HAMA) and/or human anti-chimeric antibody (HACA) response). In particular, an antibody where the individual components, such as the variable region, constant region and framework, individually and/or collectively possess low immunogenicity is useful in the present invention. The antibodies which can be used in the invention are characterized by their ability to treat patients for extended periods with good to excellent alleviation of symptoms and low toxicity. Low immunogenicity and/or high affinity, as well as other undefined properties, may contribute to the therapeutic results achieved.
An example of a high affinity monoclonal antibody useful in the methods and compositions of the present invention is murine monoclonal antibody (mAb) A2 and antibodies which will competitively inhibit in vivo the binding to human TNF.alpha. of anti-TNFα murine mAb A2 or an antibody having substantially the same specific binding characteristics, as well as fragments and regions thereof. Murine monoclonal antibody A2 and chimeric derivatives thereof, such as cA2, are described in U.S. application Ser. No. 08/192,093 (filed Feb. 4, 1994), U.S. application Ser. No. 08/192,102 (filed Feb. 4, 1994, now U.S. Pat. No. 5,656,272), U.S. application Ser. No. 08/192,861 (filed Feb. 4, 1994), U.S. application Ser. No. 08/324,799 (filed Oct. 18, 1994), and Le, J. et al., International Publication No. WO 92/16553 (published Oct. 1, 1992), which references are entirely incorporated herein by reference. A second example of a high affinity monoclonal antibody useful in the methods and compositions of the present invention is murine mAb 195 and antibodies which will competitively inhibit in vivo the binding to human TNF a of anti-TNF a murine 195 or an antibody having substantially the same specific binding characteristics, as well as fragments and regions thereof. Other high affinity monoclonal antibodies useful in the methods and compositions of the present invention include murine mAb 114 and murine mAb 199 and antibodies which will competitively inhibit in vivo the binding to human TNFα of anti-TNFα murine mAb 114 or mAb 199 or an antibody having substantially the same specific binding characteristics of mAb 114 or mAb 199, as well as fragments and regions thereof. Murine monoclonal antibodies 114, 195 and 199 and the method for producing them are described by Moller, A. et al. (Cytokine 2(3):162-169 (1990)), the teachings of which are entirely incorporated herein by reference. Preferred methods for determining mAb specificity and affinity by competitive inhibition can be found in Harlow, et al., Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory Press, Cold Spring Harbor, N.Y. (1988); Colligan et al., eds., Current Protocols in Immunology, Greene Publishing Assoc. and Wiley Interscience, New York (1992, 1993); Kozbor et al., Immunol. Today 4:72-79 (1983); Ausubel et al., eds., Current Protocols in Molecular Biology, Wiley Interscience, New York (1987, 1992, 1993); and Muller, Meth. Enzymol. 92:589-601 (1983), which references are entirely incorporated herein by reference.
Preferred anti-TNF mAbs are also those which will competitively inhibit in vivo the binding to human TNFα of anti-TNFα murine mAb A2, chimeric mAb cA2, or an antibody having substantially the same specific binding characteristics, as well as fragments and regions thereof. Preferred antibodies of the present invention are those that bind epitopes recognized by A2 and cA2, which are included in amino acids 59-80 and/or 87-108 of hTNFα (as these corresponding amino acids of SEQ ID NO:1), such that the epitopes consist of at least 5 amino acids which comprise at least one amino acid from the above portions of human TNFα.
The avidity and epitope specificity of the chimeric A2 is derived from the variable region of the murine A2. In a solid phase ELISA, cross-competition for TNF was observed between chimeric and murine A2, indicating an identical epitope specificity of cA2 and murine A2. The specificity of cA2 for TNF-.alpha. was confirmed by its inability to neutralize the cytotoxic effects of lymphotoxin (TNF-β). Chimeric A2 neutralizes the cytotoxic effect of both natural and recombinant human TNF in a dose dependent manner. From binding assays of cA2 and recombinant human TNF, the affinity constant of cA2 was calculated to be 1.8×10⁹M¹.
Since circulating concentrations of TNF tend to be extremely low, in the range of about 10 pg/ml in non-septic individuals, and reaching about 50 pg/ml in septic patients and above 100 pg/ml in the sepsis syndrome (Hammerle, A. F. et al., 1989, infra) or can be only be detectable at sites of TNF-mediated pathology, it is preferred to use high affinity and/or potent in vivo TNF-inhibiting and/or neutralizing antibodies, fragments or regions thereof, for both TNF immunoassays and therapy of TNF-mediated pathology. Such antibodies, fragments, or regions, will preferably have an affinity for hTNFα, expressed as Ka, of at least 10⁸M⁻¹, more preferably, at least 10⁹M⁻¹, such as 10⁸-10¹⁰M⁻¹, 5×10⁸M⁻¹, 8×10⁸M⁻¹, 2×10⁹M⁻¹, 4×10⁹M⁻¹, 6×10⁹M⁻¹, 8×10⁹M⁻¹, or any range or value therein.
Additional examples of monoclonal anti-TNF antibodies that can be used in the present invention are described in the art (see, e.g., U.S. application Ser. No. 07/943,852 (filed Sep. 11, 1992); Rathjen et al., International Publication No. WO 91/02078 (published Feb. 21, 1991); Rubin et al., EPO Patent Publication 0218868 (published Apr. 22, 1987); Yone et al., EPO Patent Publication No. 0288088 (Oct. 26, 1988); Liang, et al., Biochem. Biophys. Res. Comm. 137:847-854 (1986); Meager, et al., Hybridoma 6:305-311 (1987); Fendly et al., Hybridoma 6:359-369 (1987); Bringman, et al., Hybridoma 6:489-507 (1987); Hirai, et al., J. Immunol. Meth. 96:57-62 (1987); Moller, et al., Cytokine 2:162-169 (1990), which references are entirely incorporated herein by reference).
Chimeric antibodies are immunoglobulin molecules characterized by two or more segments or portions derived from different animal species. Generally, the variable region of the chimeric antibody is derived from a non-human mammalian antibody, such as a murine mAb, and the immunoglobulin constant region is derived from a human immunoglobulin molecule. Preferably, a variable region with low immunogenicity is selected and combined with a human constant region which also has low immunogenicity, the combination also preferably having low immunogenicity. “Low” immunogenicity is defined herein as raising significant HACA or HAMA responses in less than about 75%, or preferably less than about 50% of the patients treated and/or raising low titres in the patient treated (less than about 300, preferably less than about 100 measured with a double antigen enzyme immunoassay) (Elliott et al., Lancet 344:1125-1127 (1994), incorporated herein by reference).
As used herein, the term “chimeric antibody” includes monovalent, divalent or polyvalent immunoglobulins. A monovalent chimeric antibody is a dimer (HL)) formed by a chimeric H chain associated through disulfide bridges with a chimeric L chain. A divalent chimeric antibody is a tetramer (H2L2) formed by two HL dimers associated through at least one disulfide bridge. A polyvalent chimeric antibody can also be produced, for example, by employing a CH region that aggregates (e.g., from an IgM H chain, or μ chain).
Antibodies comprise individual heavy (H) and/or light (L) immunoglobulin chains. A chimeric H chain comprises an antigen binding region derived from the H chain of a non-human antibody specific for TNF, which is linked to at least a portion of a human H chain C region (CH), such as CH1 or CH2. A chimeric L chain comprises an antigen binding region derived from the L chain of a non-human antibody specific for TNF, linked to at least a portion of a human L chain C region (CL).
Chimeric antibodies and methods for their production have been described in the art (Morrison et al., Proc. Natl. Acad. Sci. USA 81:6851-6855 (1984); Boulianne et al., Nature 312:643-646 (1984); Neuberger et al., Nature 314:268-270 (1985); Taniguchi et al., European Patent Application No. 171496 (published Feb. 19, 1985); Morrison et al., European Patent Application No. 173494 (published Mar. 5, 1986); Neuberger et al., PCT Application No. WO 86/01533, (published Mar. 13, 1986); Kudo et al., European Patent Application No. 184187 (published Jun. 11, 1986); Morrison et al., European Patent Application No. 173494 (published Mar. 5, 1986); Sahagan et al., J. Immunol. 137:1066-1074 (1986); Robinson et al., International Publication No. PCT/US86/02269 (published May 7, 1987); Liu et al., Proc. Natl. Acad. Sci. USA 84:3439-3443 (1987); Sun et al., Proc. Natl. Acad. Sci. USA 84:214-218 (1987); Better et al., Science 240:1041-1043 (1988); and Harlow and Lane, Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory, New York, 1988). These references are entirely incorporated herein by reference.
The anti-TNF chimeric antibody can comprise, for example, two light chains and two heavy chains, each of the chains comprising at least part of a human constant region and at least part of a variable (V) region of non-human origin having specificity to human TNF, said antibody binding with high affinity to an inhibiting and/or neutralizing epitope of human TNF, such as the antibody cA2. The antibody also includes a fragment or a derivative of such an antibody, such as one or more portions of the antibody chain, such as the heavy chain constant or variable regions, or the light chain constant or variable regions.
Humanizing and resurfacing the antibody can further reduce the immunogenicity of the antibody. See, for example, Winter (U.S. Pat. No. 5,225,539 and EP 239,400 B1), Padlan et al. (EP 519,596 A1) and Pedersen et al. (EP 592,106 A1). These references are incorporated herein by reference.
Preferred antibodies useful in the methods and compositions of the present invention are high affinity human-murine chimeric anti-TNF antibodies, and fragments or regions thereof, that have potent inhibiting and/or neutralizing activity in vivo against human TNFα. Such antibodies and chimeric antibodies can include those generated by immunization using purified recombinant TNFα or peptide fragments thereof comprising one or more epitopes.
An example of such a chimeric antibody is cA2 and antibodies which will competitively inhibit in vivo the binding to human TNFα of anti-TNFα murine mAb A2, chimeric mAb cA2, or an antibody having substantially the same specific binding characteristics, as well as fragments and regions thereof. Chimeric mAb cA2 has been described, for example, in U.S. application Ser. No. 08/192,093 (filed Feb. 4, 1994), U.S. application Ser. No. 08/192,102 (filed Feb. 4, 1994), U.S. application Ser. No. 08/192,861 (filed Feb. 4, 1994), and U.S. application Ser. No. 08/324,799 (filed Oct. 18, 1994), and by Le, J. et al. (International Publication No. WO 92/16553 (published Oct. 1, 1992)); Knight, D. M. et al. (Mol. Immunol. 30:1443-1453 (1993)); and Siegel, S. A. et al. (Cytokine 7(1):15-25 (1995)). These references are entirely incorporated herein by reference.
Chimeric A2 anti-TNF consists of the antigen binding variable region of the high-affinity neutralizing mouse anti-human TNF IgGl antibody, designated A2, and the constant regions of a human IgGl, kappa immunoglobulin. The human IgGl Fc region improves allogeneic antibody effector function, increases the circulating serum half-life and decreases the immunogenicity of the antibody. The avidity and epitope specificity of the chimeric A2 is derived from the variable region of the murine A2. Chimeric A2 neutralizes the cytotoxic effect of both natural and recombinant human TNF in a dose dependent manner. From binding assays of cA2 and recombinant human TNF, the affinity constant of cA2 was calculated to be 1.8×10⁹M⁻¹. Preferred methods for determining mAb specificity and affinity by competitive inhibition can be found in Harlow, et al., Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory Press, Cold Spring Harbor, N.Y., 1988; Colligan et al., eds., Current Protocols in Immunology, Greene Publishing Assoc. and Wiley Interscience, New York, (1992, 1993); Kozbor et al., Immunol. Today 4:72-79 (1983); Ausubel et al., eds. Current Protocols in Molecular Biology, Wiley Interscience, New York (1987, 1992, 1993); and Muller, Meth. Enzymol. 92:589-601 (1983), which references are entirely incorporated herein by reference.
As used herein, the term “antigen binding region” refers to that portion of an antibody molecule which contains the amino acid residues that interact with an antigen and confer on the antibody its specificity and affinity for the antigen. The antibody region includes the “framework” amino acid residues necessary to maintain the proper conformation of the antigen-binding residues. Generally, the antigen binding region will be of murine origin. In other embodiments, the antigen binding region can be derived from other animal species, such as sheep, rabbit, rat or hamster. Preferred sources for the DNA encoding such a non-human antibody include cell lines which produce antibody, preferably hybrid cell lines commonly known as hybridomas. In one embodiment, a preferred hybridoma is the A2 hybridoma cell line.
An “antigen” is a molecule or a portion of a molecule capable of being bound by an antibody which is additionally capable of inducing an animal to produce antibody capable of selectively binding to an epitope of that antigen. An antigen can have one or more than one epitope.
The term “epitope” is meant to refer to that portion of the antigen capable of being recognized by and bound by an antibody at one or more of the antibody's antigen binding region. Epitopes usually consist of chemically active surface groupings of molecules such as amino acids or sugar side chains and have specific three dimensional structural characteristics as well as specific charge characteristics. By “inhibiting and/or neutralizing epitope” is intended an epitope, which, when bound by an antibody, results in loss of biological activity of the molecule containing the epitope, in vivo or in vitro, more preferably in vivo, including binding of TNF to a TNF receptor. Epitopes of TNF have been identified within amino acids 1 to about 20, about 56 to about 77, about 108 to about 127 and about 138 to about 149. Preferably, the antibody binds to an epitope comprising at least about 5 amino acids of TNF within TNF residues from about 87 to about 107, about 59 to about 80 or a combination thereof. Generally, epitopes include at least about 5 amino acids and less than about 22 amino acids embracing or overlapping one or more of these regions.
For example, epitopes of TNF which are recognized by, and/or binds with anti-TNF activity, an antibody, and fragments, and variable regions thereof, include:

	59-80:
	(SEQ ID NO: 1)
	Tyr-Ser-Gln-Val-Leu-Phe-Lys-Gly-Gln-Gly-Cys-
	Pro-Ser-Thr-His-Val-Leu-Leu-Thr-His-Thr-Ile;
	and/or

	87-108:
	(SEQ ID NO: 2)
	Tyr-Gln-Thr-Lys-Val-Asn-Leu-Leu-Ser-Ala-Ile-
	Lys-Ser-Pro-Cys-Gln-Arg-Glu-Thr-Pro-Glu-Gly.

The anti-TNF antibodies, and fragments, and variable regions thereof, that are recognized by, and/or binds with anti-TNF activity, these epitopes block the action of TNFα without binding to the putative receptor binding locus as presented by Eck and Sprang (J. Biol. Chem. 264(29): 17595-17605 (1989) (amino acids 11-13, 37-42, 49-57 and 155-157 of hTNFα). Rathjen et al., International Publication No. WO 91/02078 (published Feb. 21, 1991), incorporated herein by reference, discloses TNF ligands which can bind additional epitopes of TNF.
Antibody Production using Hybridomas
The techniques to raise antibodies to small peptide sequences that recognize and bind to those sequences in the free or conjugated form or when presented as a native sequence in the context of a large protein are well known in the art. Such antibodies can be produced by hybridoma or recombinant techniques known in the art.
Murine antibodies which can be used in the preparation of the antibodies useful in the methods and compositions of the present invention have also been described in Rubin et al., EP 0218868 (published Apr. 22, 1987); Yone et al., EP 0288088 (published Oct. 26, 1988); Liang, et al., Biochem. Biophys. Res. Comm. 137:847-854 (1986); Meager, et al., Hybridoma 6:305-311 (1987); Fendly et al., Hybridoma 6:359-369 (1987); Bringman, et al., Hybridoma 6:489-507 (1987); Hirai, et al., J. Immunol. Meth. 96:57-62 (1987); Moller, et al., Cytokine 2:162-169 (1990).
The cell fusions are accomplished by standard procedures well known to those skilled in the field of immunology. Fusion partner cell lines and methods for fusing and selecting hybridomas and screening for mAbs are well known in the art. See, e.g, Ausubel infra, Harlow infra, and Colligan infra, the contents of which references are incorporated entirely herein by reference.
The TNFα-specific murine mAb useful in the methods and compositions of the present invention can be produced in large quantities by injecting hybridoma or transfectoma cells secreting the antibody into the peritoneal cavity of mice and, after appropriate time, harvesting the ascites fluid which contains a high titer of the mAb, and isolating the mAb therefrom. For such in vivo production of the mAb with a hybridoma (e.g., rat or human), hybridoma cells are preferably grown in irradiated or athymic nude mice. alternatively, the antibodies can be produced by culturing hybridoma or transfectoma cells in vitro and isolating secreted mAb from the cell culture medium or recombinantly, in eukaryotic or prokaryotic cells.
In one embodiment, the antibody used in the methods and compositions of the present invention is a mAb which binds amino acids of an epitope of TNF recognized by A2, rA2 or cA2, produced by a hybridoma or by a recombinant host. In another embodiment, the antibody is a chimeric antibody which recognizes an epitope recognized by A2. In still another embodiment, the antibody is a chimeric antibody designated as chimeric A2 (cA2).
As examples of antibodies useful in the methods and compositions of the present invention, murine mAb A2 is produced by a cell line designated c134A.
“Derivatives” of the antibodies including fragments, regions or proteins encoded by truncated or modified genes to yield molecular species functionally resembling the immunoglobulin fragments are also useful in the methods and compositions of the present invention. The modifications include, but are not limited to, addition of genetic sequences coding for cytotoxic proteins such as plant and bacterial toxins. The fragments and derivatives can be produced from appropriate cells, as is known in the art. Alternatively, anti-TNF antibodies, fragments and regions can be bound to cytotoxic proteins or compounds in vitro, to provide cytotoxic anti-TNF antibodies which would selectively kill cells having TNF on their surface.
“Fragments” of the antibodies include, for example, Fab, Fab′, F(ab′)₂and Fv. These fragments lack the Fc fragment of intact antibody, clear more rapidly from the circulation, and can have less non-specific tissue binding than an intact antibody (Wahl et al., J. Nucl. Med. 24:316-325 (1983)). These fragments are produced from intact antibodies using methods well known in the art, for example by proteolytic cleavage with enzymes such as papain (to produce Fab fragments) or pepsin (to produce F(ab′)₂fragments).

Recombinant Expression of Anti-TNF Antibodies

Recombinant and/or chimeric murine-human or human-human antibodies that inhibit TNF can be produced using known techniques based on the teachings provided in U.S. application Ser. No. 08/192,093 (filed Feb. 4, 1994), U.S. application Ser. No. 08/192,102 (filed Feb. 4, 1994), U.S. application Ser. No. 08/192,861 (filed Feb. 4, 1994), U.S. application Ser. No. 08/324,799 (filed on Oct. 18, 1994) and Le, J. et al., International Publication No. WO 92/16553 (published Oct. 1, 1992), which references are entirely incorporated herein by reference. See, e.g., Ausubel et al., eds. Current Protocols in Molecular Biology, Wiley Interscience, New York (1987, 1992, 1993); and Sambrook et al. Molecular Cloning: A Laboratory Manual, Cold Spring Harbor Laboratory Press, New York (1989), the contents of which are entirely incorporated herein by reference. See also, e.g., Knight, D. M., et al., Mol. Immunol 30:1443-1453 (1993); and Siegel, S. A., et al., Cytokine 7(1):15-25 (1995), the contents of which are entirely incorporated herein by reference.
The DNA encoding an anti-TNF antibody can be genomic DNA or cDNA which encodes at least one of the heavy chain constant region (Hc), the heavy chain variable region (Hc), the light chain variable region (Lv) and the light chain constant regions (Lc). A convenient alternative to the use of chromosomal gene fragments as the source of DNA encoding the murine V region antigen-binding segment is the use of CDNA for the construction of chimeric immunoglobulin genes, e.g., as reported by Liu et al. (Proc. Natl. Acad. Sci., USA 84:3439 (1987) and J. Immunology 139:3521 (1987)), which references are entirely incorporated herein by reference. The use of cDNA requires that gene expression elements appropriate for the host cell be combined with the gene in order to achieve synthesis of the desired protein. The use of CDNA sequences is advantageous over genomic sequences (which contain introns), in that cDNA sequences can be expressed in bacteria or other hosts which lack appropriate RNA splicing systems. An example of such a preparation is set forth below.
Because the genetic code is degenerate, more than one codon can be used to encode a particular amino acid. Using the genetic code, one or more different oligonucleotides can be identified, each of which would be capable of encoding the amino acid. The probability that a particular oligonucleotide will, in fact, constitute the actual XXX-encoding sequence can be estimated by considering abnormal base pairing relationships and the frequency with which a particular codon is actually used (to encode a particular amino acid) in eukaryotic or prokaryotic cells expressing an anti-TNF antibody or fragment. Such “codon usage rules” are disclosed by Lathe, et al., J. Mol. Biol. 183:1-12 (1985). Using the “codon usage rules” of Lathe, a single oligonucleotide, or a set of oligonucleotides, that contains a theoretical “most probable” nucleotide sequence capable of encoding anti-TNF variable or constant region sequences is identified.
Although occasionally an amino acid sequence can be encoded by only a single oligonucleotide, frequently the amino acid sequence can be encoded by any of a set of similar oligonucleotides. Importantly, whereas all of the members of this set contain oligonucleotides which are capable of encoding the peptide fragment and, thus, potentially contain the same oligonucleotide sequence as the gene which encodes the peptide fragment, only one member of the set contains the nucleotide sequence that is identical to the nucleotide sequence of the gene. Because this member is present within the set, and is capable of hybridizing to DNA even in the presence of the other members of the set, it is possible to employ the unfractionated set of oligonucleotides in the same manner in which one would employ a single oligonucleotide to clone the gene that encodes the protein.
The oligonucleotide, or set of oligonucleotides, containing the theoretical “most probable” sequence capable of encoding an anti-TNF antibody or fragment including a variable or constant region is used to identify the sequence of a complementary oligonucleotide or set of oligonucleotides which is capable of hybridizing to the “most probable” sequence, or set of sequences. An oligonucleotide containing such a complementary sequence can be employed as a probe to identify and isolate the variable or constant region anti-TNF gene (Sambrook et al., infra).
A suitable oligonucleotide, or set of oligonucleotides, which is capable of encoding a fragment of the variable or constant anti-TNF region (or which is complementary to such an oligonucleotide, or set of oligonucleotides) is identified (using the above-described procedure), synthesized, and hybridized by means well known in the art, against a DNA or, more preferably, a cDNA preparation derived from cells which are capable of expressing anti-TNF antibodies or variable or constant regions thereof. Single stranded oligonucleotide molecules complementary to the “most probable” variable or constant anti-TNF region peptide coding sequences can be synthesized using procedures which are well known to those of ordinary skill in the art (Belagaje, et al., J. Biol. Chem. 254:5765-5780 (1979); Maniatis, et al., In: Molecular Mechanisms in the Control of Gene Expression, Nierlich, et al., eds., Acad. Press, New York (1976); Wu, et al., Prog. Nucl. Acid Res. Molec. Biol. 21:101-141 (1978); Khorana, Science 203:614-625 (1979)). Additionally, DNA synthesis can be achieved through the use of automated synthesizers. Techniques of nucleic acid hybridization are disclosed by Sambrook et al., Molecular Cloning: A Laboratory Manual, Cold Spring Harbor Laboratory Press, New York (1989); and by Haynes, et al., in: Nucleic Acid Hybridization, A Practical Approach, IRL Press, Washington, D.C. (1985), which references are entirely incorporated herein by reference. Techniques such as, or similar to, those described above have successfully enabled the cloning of genes for human aldehyde dehydrogenases (Hsu, et al., Proc. Natl. Acad. Sci. USA 82:3771-3775 (1985)), fibronectin (Suzuki, et al., Bur. Mol. Biol. Organ. J. 4:2519-2524 (1985)), the human estrogen receptor gene (Walter, et al., Proc. Natl. Acad. Sci. USA 82:7889-7893 (1985)), tissue-type plasminogen activator (Pennica, et al., Nature 301:214-221 (1983)) and human placental alkaline phosphatase complementary DNA (Keun, et al., Proc. Natl. Acad. Sci. USA 82:8715-8719 (1985)).
In an alternative way of cloning a polynucleotide encoding an anti-TNF variable or constant region, a library of expression vectors is prepared by cloning DNA or, more preferably, cDNA (from a cell capable of expressing an anti-TNF antibody or variable or constant region) into an expression vector. The library is then screened for members capable of expressing a protein which competitively inhibits the binding of an anti-TNF antibody, such as A2 or cA2, and which has a nucleotide sequence that is capable of encoding polypeptides that have the same amino acid sequence as anti-TNF antibodies or fragments thereof. In this embodiment, DNA, or more preferably CDNA, is extracted and purified from a cell which is capable of expressing an anti-TNF antibody or fragment. The purified cDNA is fragmentized (by shearing, endonuclease digestion, etc.) to produce a pool of DNA or cDNA fragments. DNA or cDNA fragments from this pool are then cloned into an expression vector in order to produce a genomic library of expression vectors whose members each contain a unique cloned DNA or cDNA fragment such as in a lambda phage library, expression in prokaryotic cell (e.g., bacteria) or eukaryotic cells, (e.g., mammalian, yeast, insect or, fungus). See, e.g., Ausubel, infra, Harlow, infra, Colligan, infra; Nyyssonen et al. Bio/Technology 11:591-595 (1993); Marks et al., Bio/Technology 11:1145-1149 (October 1993). Once nucleic acid encoding such variable or constant anti-TNF regions is isolated, the nucleic acid can be appropriately expressed in a host cell, along with other constant or variable heavy or light chain encoding nucleic acid, in order to provide recombinant monoclonal antibodies that bind TNF with inhibitory activity. Such antibodies preferably include a murine or human anti-TNF variable region which contains a framework residue having complementarity determining residues which are responsible for antigen binding.
Human genes which encode the constant (C) regions of the chimeric antibodies, fragments and regions of the present invention can be derived from a human fetal liver library, by known methods. Human C region genes can be derived from any human cell including those which express and produce human immunoglobulins. The human CH region can be derived from any of the known classes or isotypes of human H chains, including gamma, μ, α, δ or ε, and subtypes thereof, such as G1, G2, G3 and G4. Since the H chain isotype is responsible for the various effector functions of an antibody, the choice of CH region will be guided by the desired effector functions, such as complement fixation, or activity in antibody-dependent cellular cytotoxicity (ADCC). Preferably, the CH region is derived from gamma 1 (IgG1), gamma 3 (IgG3), gamma 4 (IgG4), or μ (IgM). The human CL region can be derived from either human L chain isotype, kappa or lambda.
Genes encoding human immunoglobulin C regions are obtained from human cells by standard cloning techniques (Sambrook, et al. (Molecular Cloning: A Laboratory Manual, 2nd Edition, Cold Spring Harbor Press, Cold Spring Harbor, N.Y. (1989) and Ausubel et al., eds., Current Protocols in Molecular Biology, Wiley Interscience, New York (1987-1993)). Human C region genes are readily available from known clones containing genes representing the two classes of L chains, the five classes of H chains and subclasses thereof. Chimeric antibody fragments, such as F(ab′)₂and Fab, can be prepared by designing a chimeric H chain gene which is appropriately truncated. For example, a chimeric-gene encoding an H chain portion of an F(ab′)₂fragment would include DNA sequences encoding the CH1 domain and hinge region of the H chain, followed by a translational stop codon to yield the truncated molecule.
Generally, the murine, human and chimeric antibodies, fragments and regions are produced by cloning DNA segments encoding the H and L chain antigen-binding regions of a TNF-specific antibody, and joining these DNA segments to DNA segments encoding CH and CL regions, respectively, to produce murine, human or chimeric immunoglobulin-encoding genes. Thus, in a preferred embodiment, a fused chimeric gene is created which comprises a first DNA segment that encodes at least the antigen-binding region of non-human origin, such as a functionally rearranged V region with joining (J) segment, linked to a second DNA segment encoding at least a part of a human C region.
Therefore, CDNA encoding the antibody V and C regions and the method of producing a chimeric antibody can involve several steps, outlined below:

- 1. isolation of messenger RNA (mRNA) from the cell line producing an anti-TNF antibody and from optional additional antibodies supplying heavy and light constant regions; cloning and cDNA production therefrom;
- 2. preparation of a full length cDNA library from purified mRNA from which the appropriate V and/or C region gene segments of the L and H chain genes can be: (i) identified with appropriate probes, (ii) sequenced, and (iii) made compatible with a C or V gene segment from another antibody for a chimeric antibody;
- 3. Construction of complete H or L chain coding sequences by linkage of the cloned specific V region gene segments to cloned C region gene, as described above;
- 4. Expression and production of L and H chains in selected hosts, including prokaryotic and eukaryotic cells to provide murine-murine, human-murine, human-human or human-murine antibodies.

One common feature of all immunoglobulin H and L chain genes and their encoded mRNAs is the J region. H and L chain J regions have different sequences, but a high degree of sequence homology exists (greater than 80%) among each group, especially near the C region. This homology is exploited in this method and consensus sequences of H and L chain J regions can be used to design oligonucleotides for use as primers for introducing useful restriction sites into the J region for subsequent linkage of V region segments to human C region segments.
C region cDNA vectors prepared from human cells can be modified by site-directed mutagenesis to place a restriction site at the analogous position in the human sequence. For example, one can clone the complete human kappa chain C (Ck) region and the complete human gamma-1 C region (C gamma-1). In this case, the alternative method based upon genomic C region clones as the source for C region vectors would not allow these genes to be expressed in bacterial systems where enzymes needed to remove intervening sequences are absent. Cloned V region segments are excised and ligated to L or H chain C region vectors. Alternatively, the human C gamma-1 region can be modified by introducing a termination codon thereby generating a gene sequence which encodes the H chain portion of an Fab molecule. The coding sequences with linked V and C regions are then transferred into appropriate expression vehicles for expression in appropriate hosts, prokaryotic or eukaryotic.
Two coding DNA sequences are said to be “operably linked” if the linkage results in a continuously translatable sequence without alteration or interruption of the triplet reading frame. A DNA coding sequence is operably linked to a gene expression element if the linkage results in the proper function of that gene expression element to result in expression of the coding sequence.
Expression vehicles include plasmids or other vectors. Preferred among these are vehicles carrying a functionally complete human CH or CL chain sequence having appropriate restriction sites engineered so that any VH or VL chain sequence with appropriate cohesive ends can be easily inserted therein. Human CH or CL chain sequence-containing vehicles thus serve as intermediates for the expression of any desired complete H or L chain in any appropriate host.
A chimeric antibody, such as a mouse-human or human-human, will typically be synthesized from genes driven by the chromosomal gene promoters native to the mouse H and L chain V regions used in the constructs; splicing usually occurs between the splice donor site in the mouse J region and the splice acceptor site preceding the human C region and also at the splice regions that occur within the human C, region; polyadenylation and transcription termination occur at native chromosomal sites downstream of the human coding regions.
A nucleic acid sequence encoding at least one anti-TNF antibody fragment may be recombined with vector DNA in accordance with conventional techniques, including blunt-ended or staggered-ended termini for ligation, restriction enzyme digestion to provide appropriate termini, filling in of cohesive ends as appropriate, alkaline phosphatase treatment to avoid undesirable joining, and ligation with appropriate ligases. Techniques for such manipulations are disclosed, e.g., by Ausubel, supra, Sambrook, supra, entirely incorporated herein by reference, and are well known in the art.
A nucleic acid molecule, such as DNA, is “capable of expressing” a polypeptide if it contains nucleotide sequences which contain transcriptional and translational regulatory information and such sequences are “operably linked” to nucleotide sequences which encode the polypeptide. An operable linkage is a linkage in which the regulatory DNA sequences and the DNA sequence sought to be expressed are connected in such a way as to permit gene expression as anti-TNF peptides or antibody fragments in recoverable amounts. The precise nature of the regulatory regions needed for gene expression may vary from organism to organism and is well known in the analogous art. See, e.g., Sambrook et al., Molecular Cloning: A Laboratory Manual, Cold Spring Harbor Laboratory Press, New York (1989); and Ausubel, eds., Current Protocols in Molecular Biology, Wiley Interscience, New York (1987, 1993).
Many vector systems are available for the expression of cloned anti-TNF peptide H and L chain genes in mammalian cells (see Glover, ed., DNA Cloning, Vol. II, pp. 143-238, IRL Press, Washington, D.C., 1985). Different approaches can be followed to obtain complete H2L2 antibodies. It is possible to co-express H and L chains in the same cells to achieve intracellular association and linkage of H and L chains into complete tetrameric H2L2 antibodies. The co-expression can occur by using either the same or different plasmids in the same host. Genes for both H and L chains can be placed into the same plasmid, which is then transfected into cells, thereby selecting directly for cells that express both chains. Alternatively, cells can be transfected first with a plasmid encoding one chain, for example the L chain, followed by transfection of the resulting cell line with an H chain plasmid containing a second selectable marker. Cell lines producing H2L2 molecules via either route could be transfected with plasmids encoding additional copies of peptides, H, L, or H plus L chains in conjunction with additional selectable markers to generate cell lines with enhanced properties, such as higher production of assembled H2L2 antibody molecules or enhanced stability of the transfected cell lines.

Receptor Molecules

Receptor molecules (also referred to herein as soluble TNF receptors) useful in the methods and compositions of the present invention are those that bind TNF with high affinity (see, e.g., Feldmann et al., International Publication No. WO 92/07076 (published Apr. 30, 1992), incorporated herein by reference) and possess low immunogenicity. In particular, the 55 kDa (p55 TNF-R) and the 75 kDa (p75 TNF-R) TNF cell surface receptors are useful in the present invention. Truncated forms of these receptors, comprising the extracellular domains (ECD) of the receptors or functional portions thereof, are also useful in the present invention. Truncated forms of the TNF receptors, comprising the ECD, have been detected in urine and serum as 30 kDa and 40 kDa TNF inhibitory binding proteins (Engelmann, H. et al., J. Biol. Chem. 265:1531-1536 (1990)). TNF receptor multimeric molecules and TNF immunoreceptor fusion molecules, and derivatives and fragments or portions thereof, are additional examples of receptor molecules which are useful in the methods and compositions of the present invention. The receptor molecules which can be used in the invention are characterized by their ability to treat patients for extended periods with good to excellent alleviation of symptoms and low toxicity. Low immunogenicity and/or high affinity, as well as other undefined properties, may contribute to the therapeutic results achieved.
TNF receptor multimeric molecules useful in the present invention comprise all or a functional portion of the ECD of two or more TNF receptors linked via one or more polypeptide linkers. The multimeric molecules can further comprise a signal peptide of a secreted protein to direct expression of the multimeric molecule. These multimeric molecules and methods for their production have been described in U.S. application Ser. No. 08/437,533 (filed May 9, 1995), the content of which is entirely incorporated herein by reference.
TNF immunoreceptor fusion molecules useful in the methods and compositions of the present invention comprise at least one portion of one or more immunoglobulin molecules and all or a functional portion of one or more TNF receptors. These immunoreceptor fusion molecules can be assembled as monomers, or hetero- or homo-multimers. The immunoreceptor fusion molecules can also be monovalent or multivalent. An example of such a TNF immunoreceptor fusion molecule is TNF receptor/IgG fusion protein.
TNF immunoreceptor fusion molecules and methods for their production have been described in the art (Lesslauer et al., Eur. J. Immunol. 21:2883-2886 (1991); Ashkenazi et al., Proc. Natl. Acad. Sci. USA 88:10535-10539 (1991); Peppel et al., J. Exp. Med. 174:1483-1489 (1991); Kolls et al., Proc. Natl. Acad. Sci. USA 91:215-219 (1994); Butler et al., Cytokine 6(6):616-623 (1994); Baker et al., Eur. J. Immunol. 24:2040-2048 (1994); Beutler et al., U.S. Pat. No. 5,447,851; and U.S. application Ser. No. 08/442,133 (filed May 16, 1995)). These references are entirely incorporated herein by reference. Methods for producing immunoreceptor fusion molecules can also be found in Capon et al., U.S. Pat. No. 5,116,964; Capon et al., U.S. Pat. No. 5,225,538; and Capon et al., Nature 337:525-531 (1989), which references are entirely incorporated herein by reference.
Derivatives, fragments, regions and functional portions of the receptor molecules functionally resemble the receptor molecules that can be used in the present invention (i.e., they bind TNF with high affinity and possess low immunogenicity). A functional equivalent or derivative of the receptor molecule refers to the portion of the receptor molecule, or the portion of the receptor molecule sequence which encodes the receptor molecule, that is of sufficient size and sequences to functionally resemble the receptor molecules that can be used in the present invention (i.e., bind TNF with high affinity and possess low immunogenicity). A functional equivalent of the receptor molecule also includes modified receptor molecules that functionally resemble the receptor molecules that can be used in the present invention (i.e., bind TNF with high affinity and possess low immunogenicity). For example, a functional equivalent of the receptor molecule can contain a “SILENT” codon or one or more amino acid substitutions, deletions or additions (e.g., substitution of one acidic amino acid for another acidic amino acid; or substitution of one codon encoding the same or different hydrophobic amino acid for another codon encoding a hydrophobic amino acid). See Ausubel et al., Current Protocols in Molecular Biology, Greene Publishing Assoc. and Wiley-Interscience, New York (1989).

Methotrexate

Presently available oral and intravenous formulations of methotrexate include Heumatrex® methotrexate dose pack (Lederle Laboratories, Wayne, N.J.); methotrexate tablets (Mylan Pharmaceuticals Inc., Morgantown, W. Va.; Roxane Laboratories, Inc., Columbus, Ohio); and methotrexate sodium tablets, for injection and injection (Immunex Corporation, Seattle, Wash.) and methotrexate LPF® sodium (methotrexate sodium injection) (Immunex Corporation, Seattle, Wash.). Methotrexate is also available from Pharmacochemie (Netherlands). Methotrexate prodrugs, homologs and/or analogs (e.g., folate antagonists) can also be used in the methods and compositions of the present invention. Alternatively, other immunosuppressive agents (or drugs that suppress the immune system) can be used in the methods and compositions of the present invention.

Administration

TNF antagonists, methotrexate and the compositions of the present invention can be administered to an individual in a variety of ways. The routes of administration include intradermal, transdermal (e.g., in slow release polymers), intramuscular, intraperitoneal, intravenous, subcutaneous, oral, topical, epidural, buccal, rectal, vaginal and intranasal routes. Any other therapeutically efficacious route of administration can be used, for example, infusion or bolus injection, absorption through epithelial or mucocutaneous linings, or by gene therapy wherein a DNA molecule encoding the therapeutic protein or peptide is administered to the patient, e.g., via a vector, which causes the protein or peptide to be expressed and secreted at therapeutic levels in vivo. In addition, the TNF antagonists, methotrexate and compositions of the present invention can be administered together with other components of biologically active agents, such as pharmaceutically acceptable surfactants (e.g., glycerides), excipients (e.g., lactose), carriers, diluents and vehicles. If desired, certain sweetening, flavoring and/or coloring agents can also be added.
The TNF antagonists and methotrexate can be administered prophylactically or therapeutically to an individual. TNF antagonists can be administered prior to, simultaneously with (in the same or different compositions) or sequentially with the administration of methotrexate. For example, TNF antagonists can be administered as adjunctive and/or concomitant therapy to methotrexate therapy.
For parenteral (e.g., intravenous, subcutaneous, intramuscular) administration, TNF antagonists, methotrexate and the compositions of the present invention can be formulated as a solution, suspension, emulsion or lyophilized powder in association with a pharmaceutically acceptable parenteral vehicle. Examples of such vehicles are water, saline, Ringer's solution, dextrose solution, and 5% human serum albumin. Liposomes and nonaqueous vehicles such as fixed oils can also be used. The vehicle or lyophilized powder can contain additives that maintain isotonicity (e.g., sodium chloride, mannitol) and chemical stability (e.g., buffers and preservatives). The formulation is sterilized by commonly used techniques.
Suitable pharmaceutical carriers are described in Remington's Pharmaceutical Sciences, A. Osol, a standard reference text in this field of art.
For example, a parenteral composition suitable for administration by injection is prepared by dissolving 1.5% by weight of active ingredient in 0.9% sodium chloride solution.
TNF antagonists and methotrexate are administered in therapeutically effective amounts; the compositions of the present invention are administered in a therapeutically effective amount. As used herein, a “therapeutically effective amount” is such that administration of TNF antagonist and methotrexate, or administration of a composition of the present invention, results in inhibition of the biological activity of TNF relative to the biological activity of TNF when therapeutically effective amounts of antagonist and methotrexate are not administered, or relative to the biological activity of TNF when a therapeutically effective amount of the composition is not administered. A therapeutically effective amount is preferably an amount of TNF antagonist and methotrexate necessary to significantly reduce or eliminate signs and symptoms associated with a particular TNF-mediated disease. As used herein, a therapeutically effective amount is not necessarily an amount such that administration of the TNF antagonist alone, or administration of methotrexate alone, must necessarily result in inhibition of the biological activity of TNF.
Once a therapeutically effective amount has been administered, a maintenance amount of TNF antagonist alone, of methotrexate alone, or of a combination of TNF antagonist and methotrexate can be administered to the individual. A maintenance amount is the amount of TNF antagonist, methotrexate, or combination of TNF antagonist and methotrexate necessary to maintain the reduction or elimination of the signs and symptoms associated with a particular TNF-mediated disease achieved by the therapeutically effective dose. The maintenance amount can be administered in the form of a single dose, or a series or doses separated by intervals of days or weeks.
The dosage administered to an individual will vary depending upon a variety of factors, including the pharmacodynamic characteristics of the particular antagonists, and its mode and route of administration; size, age, sex, health, body weight and diet of the recipient; nature and extent of symptoms of the disease being treated, kind of concurrent treatment, frequency of treatment, and the effect desired. In vitro and in vivo methods of determining the inhibition of TNF in an individual are well known to those of skill in the art. Such in vitro assays can include a TNF cytotoxicity assay (e.g., the WEHI assay or a radioimmunoassay, ELISA). In vivo methods can include rodent lethality assays and/or primate pathology model systems (Mathison et al., J. Clin. Invest., 81:1925-1937 (1988); Beutler et al., Science 229:869-871 (1985); Tracey et al., Nature 330:662-664 (1987); Shimamoto et al., Imunol. Lett. 17:311-318 (1988); Silva et al., J. Infect. Dis. 162:421-427 (1990); Opal et al., J. Infect. Dis. 161:1148-1152 (1990); Hinshaw et al., Circ. Shock 30:279-292 (1990)).
TNF antagonist and methotrexate can each be administered in single or multiple doses depending upon factors such as nature and extent of symptoms, kind of concurrent treatment and the effect desired. Thus, other therapeutic regimens or agents (e.g., multiple drug regimens) can be used in combination with the therapeutic co-administration of TNF antagonists and methotrexate. In a particular embodiment, a TNF antagonist is administered in multiple doses. In another embodiment, methotrexate is administered in the form of a series of low doses separated by intervals of days or weeks. Adjustment and manipulation of established dosage ranges are well within the ability of those skilled in the art.
Usually a daily dosage of active ingredient can be about 0.01 to 100 milligrams per kilogram of body weight. Ordinarily 1 to 40 milligrams per kilogram per day given in divided doses 1 to 6 times a day or in sustained release form is effective to obtain desired results. Second or subsequent administrations can be administered at a dosage which is the same, less than or greater than the initial or previous dose administered to the individual.
A second or subsequent administration is preferably during or immediately prior to relapse or a flare-up of the disease or symptoms of the disease. For example, second and subsequent administrations can be given between about one day to 30 weeks from the previous administration. Two, three, four or more total administrations can be delivered to the individual, as needed.
Dosage forms (composition) suitable for internal administration generally contain from about 0.1 milligram to about 500 milligrams of active ingredient per unit. In these pharmaceutical compositions the active ingredient will ordinarily be present in an amount of about 0.5-95% by weight based on the total weight of the composition.
The present invention will now be illustrated by the following example, which is not intended to be limiting in any way.

EXAMPLES

Example 1

Clinical Treatment of Rheumatoid Arthritis By Multiple Infusions of an Anti-TNF Antibody with and Without Methotrexate

A randomized, double-blind, placebo controlled study was conducted to evaluate the safety and efficacy of a chimeric monoclonal anti-TNF antibody (cA2) following multiple infusions of 1, 3 or 10 mg/kg cA2, alone or in combination with methotrexate, compared to multiple infusions of placebo in combination with methotrexate, in the treatment of rheumatoid arthritis (RA) in patients.

Patients

One hundred one (101) patients at six European centers who had been using methotrexate for at least 6 months, had been on a stable dose of 7.5 mg/wk for at least 4 weeks, and had active disease (according to the criteria of the American College of Rheumatology) with erosive changes on X-rays of hands and feet, were enrolled in the trial. Active disease was defined by the presence of six or more swollen joints plus at least three of four secondary criteria (duration of morning stiffness≧45 minutes; ≧6 tender or painful joints; erythrocyte sedimentation rate (ESR)≧28 mm/hour; C-reactive protein (CRP)≧20 mg/1.
In patients using corticosteroids (≦7.5 mg/day) or non-steroidal anti-inflammatory drugs (NSAIDs), the doses had been stable for 4 weeks prior to screening. The dose of corticosteroids remained stable throughout trial participation. The dose of NSAID typically also remained stable throughout trial participation.

Study Infusions

The chimeric monoclonal anti-TNF antibody (cA2) was supplied as a sterile solution containing 5 mg cA2 per ml of 0.01 M phosphate-buffered saline in 0.15 M sodium chloride with 0.01% polysorbate 80, pH 7.2. The placebo vials contained 0.1% human serum albumin in the same buffer. Before use, the appropriate amount of cA2 or placebo was diluted to 300 ml in sterile saline by the pharmacist, and administered intravenously via a 0.2 μm in-line filter over 2 hours. The characteristics of the placebo and cA2 infusion bags were identical, and the investigators and patients did not know which infusion was being administered.

Assessments

Patients were randomized to one of seven treatment groups. The number of patients in each dose (or treatment) group is indicated in Table 1. Each of the 101 patients received multiple infusions of either 0, 1, 3 or 10 mg/kg cA2. Infusions were to be administered at weeks 0, 2, 6, 10 and 14. Starting at week 0, the patients were receiving 7.5 mg/wk of methotrexate (Pharmacochemie, Netherlands) or 3 placebo tablets/week (Pharmacochemie, Netherlands). Patients were monitored for adverse events during infusions and regularly thereafter, by interviews, physical examination, and laboratory testing.
The six primary disease-activity assessments were chosen to allow analysis of the response in individual patients according to the Paulus index (Paulus, et al., Arthritis Rheumatism 33:477-484 (1990), the teachings of which are incorporated herein by reference). The assessments contributing to this index were the tender joint and swollen joint scores (60 and 58 joints, respectively, hips not assessed for swelling; graded 0-3), the duration of morning stiffness (minutes), the patient's and physician's assessment of disease severity (on a 5-point scale, ranging from 1 (symptom-free) to 5 (very severe), and erythrocyte sedimentation rate (ESR). Patients were considered to have responded if at least four of the six variables improved, defined as at least 20% improvement in the continuous variables, and at least two grades of improvement or improvement from grade 2 to 1 in the two disease-severity assessments (Paulus 20% response). Improvements of at least 50% in the continuous variables were also used (Paulus 50% response).
Other disease-activity assessments included the pain score (0-10 cm on a visual analogue scale (VAS)), an assessment of fatigue (0-10 cm VAS), and grip strength (0-300 mm Hg, mean of three measurements per hand by sphygmomanometer cuff).
The ESR was measured at each study site with a standard method (Westergen). C-reactive protein (CRP) was measured by rate nephelometry (Abbott fluorescent polarizing immunoassay). See also, Elliott et al., Lancet 344:1105-1110 (1994); Elliott et al., Lancet 344:1125-1127 (1994); and Elliott et al., Arthritis Rheum. 36(12):1681-1690 (1993), which references are entirely incorporated herein by reference.
Evaluations were performed at weeks 1, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22 and 26.

Results

The 101 patients were randomized to one of seven treatment (or dose) groups. The patients enrolled in each dose group were well matched for baseline demographics. Disease duration and swollen and tender joint counts at baseline were also well-balanced across the groups (Table 1). Table 1 also shows the maximum methotrexate dose administered within 6 months prior to randomization. Median maximum doses for each group ranged between 10 and 15 mg/week; there were no significant differences amongst the treatment groups (p=0.404).

TABLE 1

Baseline Disease Characteristics Joint Counts

Treatment Groups

Placebo

1 mg/kg cA2

	MTX+	MTX+	MTX−

Disease dur. (yrs)
Pts evaluated	14	14	15
Mean ± SD	7.6 ± 4.0	14.3 ± 12.1	7.6 ± 6.0
Median	6.9	11.4	5.2
IQ range	(4.3, 11.5)	(3.3, 24.7)	(3.4, 9.0)
Range	(1.8, 14.2)	(0.7, 37.3)	(2.5, 21.3)
Number of Swollen
joints, Paulus joint set (0-58)
Pts evaluated	14	14	15
Mean ± SD	18.1 ± 8.6	16.9 ± 7.8	21.2 ± 11.2
Median	16.5	15.5	20.0
IQ range	(12.0, 25.0)	(10.0, 25.0)	(10.0, 33.0)
Range	(6.0, 38.0)	(6.0, 29.0)	(7.0, 40.0)
Number of tender
joints, Paulus joint set (0-60)
Pts evaluated	14	14	15
Mean ± SD	31.5 ± 14.2	19.1 ± 10.7	29.9 ± 17.1
Median	27.0	16.0	30.0
IQ range	(22.0, 44.0)	(13.0, 30.0)	(14.0, 45.0)
Range	(8.0, 52.0)	(2.0, 39.0)	(6.0, 58.0)
Max dose MTX
prev. 6 mo (mg/kg)
Pts evaluated	14	14	15
Mean ± SD	13.8 ± 3.9	11.6 ± 3.5	12.8 ± 5.6
Median	15.0	11.3	12.5
IQ range	(10.0, 15.0)	(10.0, 12.5)	(10.0, 15.0)
Range	(7.5, 20.0)	(7.5, 20.0)	(7.5, 30.0)

	Treatment Groups
	3 mg/kg cA2

		MTX+	MTX−

	Disease dur. (yrs)
	Pts evaluated	15	14
	Mean ± SD	12.1 ± 9.0	7.8 ± 4.3
	Median	11.9	7.7
	IQ range	(4.3, 16.4)	(4.6, 9.8)
	Range	(0.7, 30.5)	(1.4, 17.4)
	Number of Swollen
	joints, Paulus joint set (0-58)
	Pts evaluated	15	14
	Mean ± SD	17.7 ± 5.9	19.7 ± 9.9
	Median	16.0	17.0
	IQ range	(13.0, 22.0)	(11.0, 32.0)
	Range	(10.0, 29.0)	(8.0, 34.0)
	Number of tender
	joints, Paulus joint set (0-60)
	Pts evaluated	15	14
	Mean ± SD	24.5 ± 14.4	31.2 ± 11.7
	Median	21.0	31.0
	IQ range	(12.0, 32.0)	(23.0, 39.0)
	Range	(10.0, 52.0)	(9.0, 52.0)
	Max dose MTX
	prev. 6 mo (mg/kg)
	Pts evaluated	14	13
	Mean ± SD	11.6 ± 3.3	11.7 ± 4.8
	Median	10.0	10.0
	IQ range	(10.0, 15.0)	(7.5, 12.5)
	Range	(7.5, 17.5)	(7.5, 25.0)

MTX = Methotrexate

The pre-specified primary analysis in this trial was the comparison of the total time of clinical response during the 26-week follow-up period. The results for the primary analysis are shown in Table 2. The duration of response of all cA2-treated groups, with the exception of the 1 mg/kg group not receiving methotrexate, was significantly improved (p<0.001) compared to the placebo group receiving methotrexate alone.

TABLE 2

Total Time of Response^a Based On Paulus 20% Criteria
Treatment Groups

Placebo

1 mg/kg cA2

3 mg/kg cA2

10 mg/kg cA2

Treatment

Total time of	MTX+	MTX+	MTX−	MTX+	MTX−	MTX+	MTX−	effect
response in weeks	(n = 14)	(n = 14)	(n = 15)	(n = 15)	(n = 14)	(n = 13)	(n = 15)	p-value

Median

	0	16.6	2.6	16.5	17.2	>23.1	10.4	<0.001
Minimum	0	0	0	0	0	0	0
25th percentile	0.0	6.2	2.0	7.0	4.0	2.6	6.9
75th percentile	0.0	22.5	8.0	>20.1	20.7	>24.6	>23.1
Maximum	>15.1	>26.9	15.1	>24.9	>25.9	>25.6	>26.4
p-value vs. MTX alone		<0.001	0.119	<0.001	<0.001	<0.001	<0.001

^aPatients were followed through 26 weeks following the initial infusion of cA2

The response rates at Paulus 20% are shown in Table 3. Drop-outs were considered as non-responders subsequent to their dropping out from the study. With the exception of the 1 mg/kg group not receiving methotrexate, all of the cA2-treated groups demonstrated clinical benefit through 14 weeks when the last dose of cA2 was received. Sustained clinical benefit was observed through 26 weeks (the last follow-up visit) in patients who received 3 or 10 mg/kg cA2 with methotrexate. Approximately one-half of the patients who received 3 mg/kg cA2 with methotrexate demonstrated continued clinical benefit at 26 weeks.

TABLE 3

Number of Patients Responding According To Paulus 20% Criteria
At Each Evaluation Visit

Treatment Groups

Placebo

1 mg/kg cA2

	MTX+	MTX+	MTX−
	(n = 14)	(n = 14)	(n = 15)

Pts with any response	21%	93%	80%
	(3/14)	13/14	12/15
p-value vs MTX alone		<0.001	0.006

Time post-infusion

1 Week	0%	31%	53%
	(0/14)	(4/13)	(8/15)
2 Weeks	7%	64%	57%
	(1/14)	(9/14)	(8/14)
4 Weeks^a	0%	79%	33%
	(0/14)	11/14	(5/15)
6 Weeks	0%	71%	27%
	(0/14)	10/14	(4/15)
8 Weeks^a	14%	64%	20%
	(2/14)	(9/14)	(3/15)
10 Weeks	7%	71%	20%
	(1/14)	10/14	(3/15)
12 Weeks^a	7%	57%	13%
	(1/14)	(8/14)	(2/15)
14 Weeks	0%	71%	7%
	(0/14)	10/14	(1/15)
16 Weeks^a	14%	64%	7%
	(2/14)	(9/14)	(1/15)
18 Weeks	21%	50%	13%
	(3/14)	(7/14)	(2/15)
20 Weeks	7%	54%	13%
	(1/14)	(7/13)	(2/15)
22 Weeks	7%	46%	0%
	(1/14)	(6/13)	(0/15)
26 Weeks^a	7%	21%	7%
	(1/14)	(3/14)	(1/15)

Treatment Groups

3 mg/kg cA2

10 mg/kg cA2

Treatment

	MTX+	MTX−	MTX+	MTX−	effect
	(n = 15)	(n = 14)	(n = 13)	(n = 15)	p-value

Pts with any response	80%	79%	85%	80%	<0.001
	12/15	11/14	11/13	12/15
p-value vs MTX alone	0.002	0.002	0.001	0.004

Time post-infusion

1 Week	27%	43%	31%	60%
	(4/15)	(6/14)	(4/13)	(9/15)
2 Weeks	27%	43%	62%	53%
	(4/15)	(6/14)	(8/13)	(8/15)
4 Weeks^a	40%	64%	54%	53%	0.002
	(6/15)	(9/14)	(7/13)	(8/15)
6 Weeks	47%	50%	54%	47%
	(7/15)	(7/14)	(7/13)	(7/15)
8 Weeks^a	60%	71%	69%	40%	0.003
	(9/15)	10/14	(9/13)	(6/15)
10 Weeks	67%	64%	69%	53%
	10/15	(9/14)	(9/13)	(8/15)
12 Weeks^a	67%	64%	62%	60%	<0.001
	10/15	(9/14)	(8/13)	(8/13)
14 Weeks	60%	57%	77%	53%
	(9/15)	(8/14)	10/13	(8/15)
16 Weeks^a	67%	64%	54%	67%	<0.001
	10/15	(9/14)	(7/13)	10/15
18 Weeks	71%	69%	62%	57%
	10/14	(9/13)	(8/13)	(8/14)
20 Weeks	53%	43%	54%	53%
	(8/15)	(6/14)	(7/13)	(8/15)
22 Weeks	47%	36%	54%	33%
	(7/15)	(5/14)	(7/13)	(5/15)
26 Weeks^a	47%	21%	54%	33%	0.013
	(7/15)	(3/14)	(7/13)	(5/15)

^aEvaluation visits pre-specified for analysis.

The response rates at Paulus 50% are shown in Table 4. The magnitude of the clinical benefit of cA2 treatment was substantial. The majority of patients were responding to cA2 treatment according to the 50% Paulus criteria.

TABLE 4

Number of Patients Responding According To Paulus 50% Criteria
At Each Evaluation Visit

Treatment Groups

Placebo

1 mg/kg cA2

	MTX+	MTX+	MTX−
	(n = 14)	(n = 14)	(n = 15)

Pts with any response	14.3%	85.7%	40.0%
	(2/14)	(12/14)	(6/15)
p-value vs MTX alone		<0.001	0.079

Time post-infusion

1 Week	0.0%	7.7%	26.7%
	(0/14)	(1/13)	(4/15)
2 Weeks	0.0%	21.4%	28.6%
	(0/14)	(3/14)	(4/14)
4 Weeks^a	0.0%	57.1%	13.3%
	(0/14)	(8/14)	(2/15)
6 Weeks	0.0%	57.1%	0.0%
	(0/14)	(8/14)	(0/15)
8 Weeks^a	7.1%	50.0%	0.0%
	(1/14)	(7/14)	(0/15)
10 Weeks	0.0%	57.1%	0.0%
	(0/14)	(8/14)	(0/15)
12 Weeks^a	7.1%	50.0%	6.7%
	(1/14)	(7/14)	(1/15)
14 Weeks	0.0%	57.1%	6.7%
	(0/14)	(8/14)	(1/15)
16 Weeks^a	0.0%	64.3%	6.7%
	(0/14)	(9/14)	(1/15)
18 Weeks	7.1%	50.0%	6.7%
	(1/14)	(7/14)	(1/15)
20 Weeks	7.1%	53.8%	0.0%
	(1/14)	(7/13)	(0/15)
22 Weeks	0.0%	38.5%	0.0%
	(0/14)	(5/13)	(0/15)
26 Weeks^a	0.0%	21.4%	6.7%
	(0/14)	(3/14)	(1/15)

Treatment Groups

3 mg/kg cA2

10 mg/kg cA2

Treatment

	MTX+	MTX−	MTX+	MTX−	effect
	(n = 15)	(n = 14)	(n = 13)	(n = 15)	p-value

Pts with any	73.3%	64.3%	76.9%	66.7%	<0.001
response	(11/15)	(9/14)	(10/13)	(10/15)
p-value vs	0.001	0.008	0.002	0.009
MTX alone

Time post-infusion

1 Week	0.0%	35.7%	7.7%	26.7%
	(0/15)	(5/14)	(1/13)	(4/15)
2 Weeks	6.7%	28.6%	15.4%	20.0%
	(1/15)	(4/14)	(2/13)	(3/15)
4 Weeks^a	13.3%	28.6%	46.2%	40.0%	0.006
	(2/15)	(4/14)	(6/13)	(6/15)
6 Weeks	26.7%	42.9%	38.5%	33.3%
	(4/15)	(6/14)	(5/13)	(5/15)
8 Weeks^a	40.0%	50.0%	69.2%	33.3%	<0.001
	(6/15)	(7/14)	(9/13)	(5/15)
10 Weeks	40.0%	50.0%	69.2%	40.0%
	(6/15)	(7/14)	(9/13)	(6/15)
12 Weeks^a	60.0%	35.7%	61.5%	40.0%	<0.001
	(9/15)	(5/14)	(8/13)	(6/15)
14 Weeks	40.0%	35.7%	61.5%	40.0%
	(6/15)	(5/14)	(8/13)	(6/15)
16 Weeks^a	60.0%	50.0%	53.8%	40.0%	<0.001
	(9/15)	(7/14)	(7/13)	(6/15)
18 Weeks	71.4%	46.2%	61.5%	57.1%
	(10/14)	(6/13)	(8/13)	(8/14)
20 Weeks	53.3%	35.7%	46.2%	40.0%
	(8/15)	(5/14)	(6/13)	(6/15)
22 Weeks	46.7%	14.3%	53.8%	26.7%
	(7/15)	(2/14)	(7/13)	(4/15)
26 Weeks^a	40.0%	14.3%	46.2%	20.0%	0.008
	(6/15)	(2/14)	(6/13)	(3/15)

^aEvaluation visits pre-specified for analysis.

Commensurate with the clinical response rates shown in Tables 2-4, most of the patients in the treatment groups demonstrating effectiveness of cA2 treatment received all 5 infusions of cA2 (Table 5). The principle reason for patients not receiving the complete dose regimen was because of lack of efficacy in the placebo group (methotrexate alone) and in the 1 mg/kg group not receiving methotrexate. All 15 patients in the 3 mg/kg group that received methotrexate completed the 5-infusion dose regimen.

TABLE 5

Number of Infusions Completed
Treatment Groups

Placebo

1 mg/kg cA2

3 mg/kg cA2

10 mg/kg cA2

	MTX+	MTX+	MTX−	MTX+	MTX−	MTX+	MTX−
	(n = 14)	(n = 14)	(n = 15)	(N = 15)	(n = 14)	(n = 14)	(n = 15)	Treatment effect

Pts with complete^ainfusions	p-value

5 infusions	6 (42.86%)	12 (85.71%)	8 (53.33%)	15 (100.00%)	12 (85.71%)	12 (85.71%)	12 (80.00%)	0.003
4 infusions	0 (0.00%)	1 (7.14%)	0 (0.00%)	0 (0.00%)	1 (7.14%)	1 (7.14%)	0 (0.00%)
3 infusions	2 (14.29%)	1 (7.14%)	6 (40.00%)	0 (0.00%)	0 (0.00%)	1 (7.14%)	1 (6.67%)
2 infusions	5 (35.71%)	0 (0.00%)	1 (6.67%)	0 (0.00%)	1 (7.14%)	0 (0.00%)	2 (13.33%)
1 infusion	1 (7.14%)	0 (0.00%)	0 (0.00%)	0 (0.00%)	0 (0.00%)	0 (0.00%)	0 (0.00%)

^aPatients are counted only once for the first group for which they qualify (5 infusions > 4 infusions etc. . . .). Patients were only counted if they had completed the entire infusion.

Results for measures of swollen and tender joint counts and the physician and patient global assessments are shown in FIGS. 1-4. The median results in FIGS. 1-4 were reported for each evaluation visit based only on the patients with data collected. That is, a last observation carried forward approach was not used for patients who dropped out. Instead, the number of patients with data that comprise each point on the graph was reported at the bottom of the figures.
Despite the number of drop-outs in the placebo group and the 1 mg/kg group not receiving methotrexate, the results in FIGS. 1-4 demonstrate that cA2 treatment in combination with methotrexate profoundly reduces disease activity for all of the traditional measurements of disease activity, approaching near remission in many patients.
Results for a commonly used serum marker of inflammatory activity, C-reactive protein (CRP) are shown in FIG. 5. Treatment with cA2 produced a rapid decrease in CRP concentration which was sustained through 26 weeks in the patients who received 3 or 10 mg/kg cA2.
Results for the Health Assessment Questionnaire (HAQ) are shown in FIG. 6. This measurement of quality of life/disability demonstrated improvement over time corresponding with the clinical improvement observed in patients treated with cA2. In the patients treated with 3 mg/kg cA2 and methotrexate, the HAQ decreased from 2.0 at baseline to 1.1 at 22 weeks.

Pharmacokinetics of cA2

Serum concentrations of cA2 were obtained in all patients in this study. The serum concentration in each patient plotted over time according to the cA2 dose group is shown in FIG. 7. Data plotted are the serum cA2 concentrations obtained just before the administration of cA2 at weeks 2, 6, 10 and 14 and then at weeks 18 and 26. These sampling times were selected to best demonstrate the stability of the cA2 concentration during the multiple dose regimen and the decline in serum cA2 concentration after the last dose was administered. For purposes of data presentation, the scales for cA2 concentration for each graph are condensed as the cA2 dose was increased.
Substantial differences were observed for the cA2 serum concentration over time in the 1 mg/kg dose groups according to whether patients received methotrexate. Most of the patients receiving 1 mg/kg cA2 with methotrexate demonstrated measurable cA2 concentrations through 18 weeks, although it appeared that there was a tendency for the concentration to decline over time. In sharp contrast, the majority of patients who received 1 mg/kg cA2 without methotrexate were not able to maintain measurable serum concentrations of cA2 over time. As discussed herein, the inability to maintain serum cA2 in these patients was associated with a high rate of neutralizing antibody formation.
In contrast to the 1 mg/kg groups, patients who received either 3 mg/kg cA2 or 10 mg/kg cA2 were able to maintain serum cA2 concentrations through the multiple dose regimen. However, even in those dose groups, there was evidence that concomitant treatment with methotrexate was associated with high cA2 serum concentrations. As shown in FIG. 8, the median serum cA2 concentration in both the 3 and 10 mg/kg dose groups receiving methotrexate was higher than in the corresponding groups not receiving methotrexate.

Immune Responses to cA2

Serum samples were collected through 26 weeks from all patients and analyzed for human anti-chimeric antibodies (HACA) to cA2. The results for HACA responses for each cA2 treatment group are shown in Table 6. It should be noted that in several patients in the 3 mg/kg group and in most patients in the 10 mg/kg group, cA2 was still present in the 26-week sample and could potentially interfere with the detection of HACA in the assay. However, it could also be reasoned that if neutralizing antibodies were present—at 26 weeks, then cA2 should not be present. Therefore, in presenting the data in Table 6, results for the immune response rate are shown not including patients with serum cA2 at 26 weeks and including patients with serum cA2 at 26 weeks, assuming that if cA2 was present at 26 weeks, the patient did not have a positive HACA response.

TABLE 6

HACA Responses

1 mg/kg

3 mg/kg

10 mg/kg

	MTX+	MTX−	MTX+	MTX−	MTX+	MTX−

HACA responses not	2/13 (15.4%)	8/15 (53.3%)	0/10 (0%)	3/12 (25.0%)	0/2 (0%)	1/10 (10%)
including pts with 26-week
serum cA2
HACA responses
	2/13 (15.4%)	8/15 (53.3%)	0/15 (0%)	3/14 (21.4%)	0/14 (0%)	1/15 (6.7%)
including pts with
26-week serum cA2¹

¹Patients with a measurable 26-week serum cA2 concentration were considered negative for a HACA response for this analysis.

Results in Table 6 demonstrate that concomitant methotrexate treatment suppresses the immune response to cA2, enabling stable pharmacokinetics to be achieved in a multiple dose regimen of cA2. This effect was also found after combined anti-CD4/anti-TNF antibody treatment in mice with collagen-induced arthritis and described in U.S. application Ser. No. 08/607,419, filed Feb. 28, 1996, the teachings of which are entirely incorporated herein by reference.

Clinical Safety

Two out of 86 patients (with most patients receiving 5 treatments) experienced multisystem infusion-related reactions with retreatment. Multisystem, infusion-related reactions include headache, fever, facial flushing, pruritus, myalgia, nausea, chest tightness, dyspnea, vomiting, erythema, abdominal discomfort, diaphoresis, shivers, hypertension, lightheadedness, hypotension, palpitations and somnolence.
Hypersensitivity reactions, as described herein, may occur whenever protein-containing materials, such as cA2, are administered. Thus, it is unclear whether these symptoms represent an immunologic event or physical factors such as infusion rate and immunoglobulin aggregation. Investigators have reported that symptoms resolve in some patients by decreasing the rate of the infusion. Previous literature reports indicate that vasomotor symptoms have been observed in patients receiving intravenous immunoglobulin therapy (Berkman et al., Ann. Intern Med. 112:278-292 (1990); Ochs et al., Lancet 2:1158-1159 (1980)).
One patient developed hypotension during all three infusions of 10 mg/kg cA2. The patient did not display clinical signs of hypotension and did not require medical treatment, but, in keeping with predefined safety criteria, the treatment schedule of this patient was discontinued.
One patient treated with 3 infusions of 10 mg/kg of cA2 and with 7.5 mg/week methotrexate developed symptoms of sepsis as a result of staphylococcal pneumonia 2 weeks after her last study visit and 14 weeks after her last infusion with cA2. Six days after developing symptoms she was admitted to the hospital and treated. She died one day later. (This patient had not proceeded with the fourth infusion for reasons unrelated to the sepsis.) Patients with RA who develop infections have a worse than expected outcome. Wolfe and coworkers have reported an observed:expected ratio for death due to pneumonia of 5.307 and an observed:expected ratio for death due to infections (excluding pneumonia) of 6.213 in RA patients from the ARAMIS database (Wolfe et al., Arthritis Rheumatism 4:481-494 (1994)).
One patient experienced a serious postoperative infection following cataract surgery 9 weeks after the fifth and last infusion of 3 mg/kg of cA2 (with 7.5 mg/week methotrexate), leading to removal of the eye. This patient was receiving prednisolone (7 mg/day). The incidence of endophthalmitis after cataract extraction has been reported to be between 0.072 and 0.093% (Kattan et al., Ophthalmology 98(9):1147-1148 (1991)) and may be heightened in patients receiving corticosteroid therapy.
Eight (9%) of 87 patients developed double stranded (ds)-DNA antibodies following multiple infusions of cA2. Measurements were performed at baseline, week 8, 16 and 26 (12 weeks following the last infusion). In these patients with antibodies against ds-DNA, there was a trend toward a lower level in antibodies at the last evaluation, with two patients being negative.
One patient developed dyspnea, pleuritic chest pain and a rebound of arthritis activity at study week 14 (four weeks after the fourth infusion of 3 mg/kg of cA2). Symptoms resolved and she received her fifth dose of cA2. Symptoms recurred 3 weeks later. Examination of the serial blood samples revealed that the test for antinuclear antibodies and anti ds-DNA antibodies were negative prior to treatment, but became positive at week 6 of the study. The patient's symptoms responded to oral prednisolone 20-30 mg daily. The working diagnosis was systemic lupus erythematosus (SLE). The patient currently does not have symptoms of SLE but has active RA.
To date, although antibodies to ds-DNA have been detected in patients treated with cA2, they generally represent transient increases and only one patient has been symptomatic. In patients who have had sufficient follow-up, anti-ds-DNA antibodies have resolved with discontinuation of treatment.
In summary, treatment with cA2 is well tolerated. The reductions in disease activity produced by cA2 are significant as supported by the findings of a low placebo response rate. High clinical response rates are obtained with a multiple dose regimen of 3 mg/kg cA2 in combination with 7.5 mg/wk methotrexate and can be sustained through 26 weeks. This dose regimen is considered preferable to the 1 mg/kg plus methotrexate regimen because better pharmacokinetics are obtained, virtually no immune response was detected and the clinical response is better sustained following the last treatment with cA2. The clinical benefit obtained by increasing the dose regimen to 10 mg/kg cA2 plus methotrexate is similar to that observed with the 3 mg/kg cA2 plus methotrexate regimen.
Thus, the results of this study indicate that treatment with a multiple dose regimen of cA2 as adjunctive and/or concomitant therapy to methotrexate therapy, in RA patients whose disease is incompletely controlled by methotrexate, produces a highly beneficial or synergistic clinical response that can be sustained through 26 weeks. The benefit produced by cA2 generally exceeds 50% reductions in the traditional measurements of rheumatoid arthritis (swollen and tender joints, patient and physician global disease assessments) and achieves near clinical remission in many patients. Accordingly, the results of this study indicate that treatment with multiple infusions of cA2 as adjunctive and/or concomitant therapy to methotrexate therapy is an important and efficacious therapeutic approach for treating RA in patients.

Example 2

Clinical Treatment of Rheumatoid Arthritis by Single Infusion of an Anti-TNF Antibody in Patients Receiving Methotrexate

A randomized, double-blind, placebo controlled study was conducted to evaluate the effects of a single infusion of placebo, 5, 10 or 20 mg/kg cA2 in combination with methotrexate, administered at a dose of 10 mg/week, in the treatment of rheumatoid arthritis (RA) in patients.

Patients

Twenty-eight (28) RA patients at three centers in the United States who, despite receiving three months therapy with methotrexate administered at a stable dose of 10 mg/wk for at least 4 weeks prior to screening, still had active disease according to the criteria of the American College of Rheumatology, were enrolled in the study. Active disease was defined by the presence of six or more swollen joints plus at least three of four secondary criteria (duration of morning stiffness≧45 minutes; ≧6 tender or painful joints; erythrocyte sedimentation rate (ESR)≧28 mm/hour; C-reactive protein (CRP)≧20 mg/l.
Patients taking NSAIDs and corticosteroids (prednisone) at screening were allowed to continue at stable doses (7.5 mg/day).

Study Infusions

Assessments

Patients were randomized to one of four treatment groups (7 patients per group). Each of the 28 patients received a single dose of either 0, 5, 10 or 20 mg/kg cA2 and were followed for 12 weeks. Patients continued treatment with methotrexate (Pharmacochemie, Netherlands) administered at 10 mg/week throughout the study. Patients were monitored for adverse events during infusions and regularly thereafter, by interviews, physical examination, and laboratory testing.
The primary measurement of clinical response was defined by the ACR preliminary definition of response (Felson et al., Arthritis Rheumatism 38(6):727-735 (1995)). Patients were considered to have a response if they had a 20% reduction in swollen and tender joint count, and had experienced a 20% reduction in 3 of the 5 following assessments: patient's assessment of pain (VAS), patient's global assessment of disease activity (VAS), physician's global assessment of disease activity (VAS), patient's assessment of physical function (HAQ), and an acute phase reactant (ESR). The ESR was measured at each study site with a standard method (Westergen).
Evaluations were performed at day 3, and at weeks 1, 2, 4, 6, 8, 10, and 12.

Results

The 28 patients were randomized to one of four treatment (or dose) groups.
The clinical response rates over time by ACR 20% criteria in each of the treatment groups is shown in Table 7.

TABLE 7

Clinical Response Rates (By ACR 20% Criteria) In Patients Receiving
10 mg/kg Methotrexate

Dose of cA2

cA2 Treated

	Placebo	5 mg/kg	10 mg/kg	20 mg/kg	Patients

Pts	7	7	7	7	21
evaluated
Pts with	1 (14.3%)	6 (85.7%)	5 (71.4%)	6 (85.7%)	17 (81.0%)
any
response
1 Week	0 (0.0%)	4 (57.1%)	2 (28.6%)	5 (71.4%)	11 (52.4%)
2 Weeks	0 (0.0%)	4 (57.1%)	5 (71.4%)	5 (71.4%)	14 (66.7%)
4 Weeks	1 (14.3%)	3 (42.9%)	5 (71.4%)	5 (71.4%)	13 (61.9%)
6 Weeks	0 (0.0%)	3 (42.9%)	5 (71.4%)	4 (57.1%)	12 (57.1%)
8 Weeks	1 (14.3%)	3 (42.9%)	4 (57.1%)	4 (57.1%)	11 (52.4%)
10 Weeks	1 (14.3%)	1 (14.3%)	4 (57.1%)	3 (42.9%)	8 (38.1%)
12 Weeks	1 (14.3%)	2 (28.6%)	4 (57.1%)	3 (42.9%)	9 (42.9%)

Clinical benefit of cA2 treatment was evident at the first evaluation visit at one week. Although each of the 3 doses of cA2 produced clinical responses in the majority of patients treated, the duration of clinical response appeared to be better sustained through 12 weeks in the groups receiving 10 or 20 mg/kg cA2. Clinical response was achieved much more frequently among patients receiving cA2 as compared to placebo. That is, 17/21 (81%) patients in the 3 cA2 groups achieved a response, compared with only 1/7 (14%) placebo treated patients. The magnitude of clinical response was notable. The mean tender joint count among cA2 treated patients decreased from 30.1 at baseline to 13.3 at week 12, and mean CRP decreased from 3.0 at baseline to 1.1 at week 12.
The duration of clinical response appeared to be dose dependent. 2/6 (33%) of the responding patients treated with 5 mg/kg cA2 sustained a response through 12 weeks of followup, compared to 7/11 (64%) of the responding patients who received 10 or 20 mg/kg. Treatment in all groups was generally well tolerated.
In summary, the results of this study indicate that treatment with cA2 as adjunctive and/or concomitant therapy to methotrexate therapy is effective in the reduction of the signs and symptoms of rheumatoid arthritis in patients whose disease is incompletely controlled by methotrexate. Moreover, the clinical response achieved by this approach can be sustained for more than 12 weeks after a single treatment. Accordingly, the results of this study indicate that treatment with cA2 as adjunctive and/or concomitant therapy to methotrexate therapy is an important and efficacious therapeutic approach for treating RA in patients.

Example 3

Clinical Treatment of Rheumatoid Arthritis by Repeated Dose Administration of an Anti-TNF Antibody in Patients Following a Single Dose, Double-Blind, Placebo-Controlled Trial

An open label study was conducted to evaluate the effects of repeated infusions of 10 mg/kg cA2 in combination with methotrexate, administered at a dose of 10 mg/week, in the treatment of rheumatoid arthritis in patients.

Patients

As described in Example 2, a randomized, double-blind, placebo controlled, 12 week study of cA2 was conducted in RA patients who had active disease despite receiving three months therapy with methotrexate administered at a stable dose of 10 mg/wk for at least 4 weeks prior to screening.
At week 12, patients who had completed the 12 week evaluation period and had not experienced adverse events prohibiting further infusions of cA2, were offered 3 subsequent open label infusions of cA2, administered at a dose of 10 mg/kg, at eight week intervals ( weeks 12, 20, 28). Twenty-three (23) patients from the 12 week study were enrolled in this study.

Assessments

11/23 patients entering this open label study were evaluated at 1 of 3 centers in the United States and followed up to 40 weeks after initial entry. Patients continued treatment with methotrexate administered at 10 mg/week throughout the study. Repeated treatments with cA2 were generally well tolerated. Three patients had transient infusion related symptoms (urticaria, somnolence).
The primary measurement of clinical response was defined by the ACR preliminary definition of response (Felson et al., Arthritis Rheumatism 38(6):727-735 (1995)). Patients were considered to have a response if they had a 20% reduction in swollen and tender joint count, and had experienced a 20% reduction in 3 of the 5 following assessments: patient's assessment of pain (VAS), patient's global assessment of disease activity (VAS), physician's global assessment of disease activity (VAS), patient's assessment of physical function (HAQ), and an acute phase reactant (ESR). The ESR was measured at each study site with a standard method (westergen).

Results

Of six patients who had all received cA2 during the double-blinded study described in Example 2 and responded through the 12 weeks of that study, four patients sustained a response throughout the 40 week followup. Of the remaining two patients, one patient is still responding through week 28, and one patient recently entered this open label trial. For all 4 patients completing 40 weeks of followup and the patient at week 28, final tender joint counts were 2 and swollen joint counts 1, compared to a mean of 23 and 29, respectively, at entry into the double-blinded study described in Example 2. For 4 of these 5 patients, ESR were 18 mm/hr and CRP 0.7, compared to a mean of 27 and 3.9, respectively, at entry into the double-blind study described in Example 2.
Of two patients who had both received cA2 during the double-blinded study described in Example 2 and responded only through week 10 of that study, one patient responded through 36 weeks and one patient is still responding through week 20.
Of three patients who did not respond during the double-blinded study described in Example 2 (2 received placebos, 1 received 5 mg/kg cA2), two of these patients experienced a transient clinical response, and one patient is still responding through week 20.
In summary, the preliminary results of this study suggest that repeated adjunctive and/or concomitant therapy with cA2, in RA patients whose disease is incompletely controlled by methotrexate, can result in substantial clinical improvement for a majority of the patients. Moreover, the clinical response achieved by this approach can be sustained for up to 40 weeks of followup. Accordingly, the results of this study indicate that repeated treatment with cA2 as adjunctive and/or concomitant therapy to methotrexate therapy is an important and efficacious therapeutic approach for treating RA in patients.

Exemplification: Treatment of Induced Arthritis in a Murine Model.

The murine model of collagen type II induced arthritis has similarities to rheumatoid arthritis (RA) in its marked MHC class II predisposition, as well as in histology, immunohistology, erosions of cartilage and bone, and in its response to anti-TNF therapy. Thus the animal model serves as a good approximation to human disease. The model of rheumatoid arthritis used herein is describe by Williams, R. O. et al., (PNAS, in press), i.e., the collagen type II induced arthritis in the DBA/1 mouse.
DBA/1 mice, aged 8-12 weeks were immunized intradermally with 100 μg of bovine type II collagen in complete Freund's adjuvant, and 21 days later with 100 μg of collagen intra-peritoneally (i.p.). Immediately after the onset of clinically evident arthritis (redness and/or swelling in on or more limbs), which was about 35 days after the initial injection, mice were injected i.p. with anti-CD4; anti-TNF; anti-CD4 and anti-TNF; or isotype controls. Arthritis was monitored for clinical score and paw-swelling for 10 days, after which time the joints were processed for histology. Antibody was injected on day 1 (onset of arthritis is day 0), day 4 and day 7.
Two experiments were completed, assessing clinical score and pawswelling. In each, 200 μg of anti-CD4 were used pre injection (rat YTS 191 and YTA 3.1) was used. Clinical score was assessed on the following scale: 0=normal; 1=slight swelling and/or erythema; 2=pronounced edematoma swelling; and 3=joint rigidity. Each limb was graded, giving a maximum score of 12 per mouse. Pawswelling was monitored by measuring the thickness of each affected hind paw with calipers. The results were expressed as the percentage increment in paw width relative to the paw width before the onset of arthritis.
In the first experiment, a single dose of 50 μg per injection of anti-TNF (hamster TN3.19.2) was administered to each of five mice per group. There was no significant effect of anti-CD4 or anti-TNF (TN3.19 given 3 times at 50 μg/mouse). Hence the benefit of combination therapy, in both clinical score and footpad swelling, is readily seen (see FIGS. 1 a, 1 b).
In the second experiment, either 50 μg and 300 μg of anti-TNF were administered to each of 7 mice per group. Both anti-CD4 and anti-TNF at low (50 μg) concentration had some effect, and benefit of combination therapy of these two concentrations was noted in pawswelling, not in clinical score. However, if anti-TNF was injected at 300 μg/mouse, the benefit of combination therapy with anti-CD4 was seen in both clinical score and more clearly in paw-swelling (see FIGS. 2 a, 2 b, 2 c, 2 d).
The results of the experiments indicate that there is a clear benefit to combination therapy with anti-TNF and anti-CD4 antibodies, as measure by clinical score and foot pad swelling.

Study 2

Male DBA/1 mice were immunized intradermally at 8-12 weeks of age with 100 μg type II collagen emulsified in Freund's complete adjuvant. Day one of arthritis was considered to be the day that erythema and/or swelling was first observed in one or more limbs. Arthritis became clinically evident around 30 days after immunization with type II collagen. For each mouse, treatment was started on the first day that arthritis was observed and continued over a 10 day period, after which the mice were sacrificed and joints were processed for histology. Monoclonal antibody treatment was administered on days 1, 4 and 7. First, a sub-optimal dose of 50 μg of anti-TNF alone (TN3-19.12, hamster IgG1 anti-TNFα/β mAb) was compared with the same does given together with 200 μg of anti-CD4 (rat IgG2b, a mixture of YTS 191.1.2 and YTA 3.1.2). To verify the results, two separate but identical experiments were carried out (11-12 mice/group and 7-8 mice/group, respectively). Neither anti-CD4 alone nor sub-optimal anti-TNF alone were able to significantly reduce paw-swelling (Data not shown). However, treatment with anti-TNF and anti-CD4 resulted in a consistently and statistically significant reduction in paw-swelling relative to the group given control mAb (P<0.001). Furthermore, in both experiments, combined anti-TNF/anti-CD4 treatment (also referred to herein as anti-CD4/TNF treatment) produced a significant reduction in paw-swelling relative to anti-CD4 alone, and anti-TNF alone (P<0.05).
Next, an optimal dose of anti-TNF (300 μg) alone was compared in two separate but identical experiments (7-7 mice/group and 6-7 mice/group, respectively) with the same dose given in combination with anti-CD4. As before, the combined anti-TNF/anti-CD4 treatment resulted in a significant reduction in paw-swelling compared to treatment with the control mAb (P<0.005; data not shown). In the first experiment, paw-swelling was also significantly reduced in the combined anti-CD4/anti-TNF treated group relative to the groups given anti-CD4 alone of anti-TNF alone (P<0.005). Some reduction in paw-swelling was observed in mice given either anti-TNF alone or anti-CD4 alone although the differences were not significant, possibly because of the small group sizes (6 per group). In the second experiment, combined anti-CD4/anti-TNF gave significantly reduced paw-swelling compared to anti-CD4 alone (P<0.05) but not compared to anti-TNF alone since anti-TNF itself causes a significant reduction in paw-swelling, as expected from previous work (Williams, R. O. et al., PNAS 89: 9784-9788 (1992)). In the experiments, the reduction in paw-swelling attributable to anti-TNF alone was 23% and 33%, respectively. Thuse, the reduction in paw-swelling attributable to anti-TNF treatment was broadly comparable with our previously published findings in which treatment with TN3-119.12 (300 μg/mouse) resulted in a mean reduction in paw-swelling over the treatment period of around 34% relative to controls (Williams, R. O. et al., PNAS 89: 9784-9788 (1992)).
Limb Involvement
In collagen-induced arthritis, as in RA, it is usually for additional limbs to become involved after the initial appearance of clinical disease and new limb involvement is an important indicator of the progression of the disease. To determine the effect of anti-CD4/anti-TNF treatment on new limb involvement, the number of limbs with clinically detectable arthritis at the end of the 10 day treatment period was compared with the number of arthritis limbs before treatment. In mice given the control mAb there was an increase in limb involvement over the 10 day period of approximately 50%. The results from the two experiments were pooled, and are shown in table 1.

TABLE 1

Combined anti-CD4/anti-TNF Inhibits
Progression of Clinical Arthritis

	Number of Limbs Affected
	(Mean ± SEM)	Increase

	Treatment	Day	1	Day 10	(%)

Sub-optimal anti-TNF (50 μg)

anti-CD4	1.30 ± 0.10	1.90 ± 0.13	46.1
(n = 18)
anti-TNF	1.20 ± 0.09	1.65 ± 0.17	37.5
(n = 19)
anti-CD4/TNF	1.40 ± 0.09	1.45 ± 0.22	3.4¹
(n = 18)
control mAb	1.43 ± 0.15	2.24 ± 0.18	56.6
(n = 18)

Optimal anti-TNF (300 μg)

	anti-CD4	1.27 ± 0.10	1.80 ± 0.14	42.0
	(n = 12)
	anti-TNF	1.50 ± 0.17	1.64 ± 0.20	9.5²
	(n = 11)
	anti-CD4/TNF	1.25 ± 0.11	1.25 ± 0.11	0³
	(n = 13)
	control mAb	1.53 ± 0.19	2.27 ± 0.25	47.8
	(n = 12)

¹P < 0.05 (anti-CD4/TNF vs. control mAb)
²P < 0.05 (anti-TNF vs. control mAb)
³P < 0.005 (anti-CD4/TNF vs. control mAb)

There was some reduction in new limb involvement in the groups given anti-CD4 alone and sub-optimal anti-TNF alone, although the differences were not significant. In the group given optimal anti-TNF the increase in limb involvement was less than 10% (P<0.05). More striking, however, was the almost complete absence of new limb involvement in the groups given combined anti-CD4/anti-TNF. Thus, the increase in new limb involvement was only 3% in mice given anti-CD4 plus suboptimal anti-TNF (P<0.05) and 0% in mice given anti-CD4 plus optimal anti-TNF (P<0.005).

Histology

After 10 days, the mice were sacrificed; the first limb that had shown clinical evidence of arthritis was removed from each mouse, formalin-fixed, decalcified, and wax-embedded before sectioning and staining with haemotoxylin and eosin. A saggital section of the proximal interphalangeal (PIP) joint of the middle digit was studied in a blind fashion for the presence or absence of erosions in either cartilage or bone (defined as demarcated defects in cartilage or bone filled with inflammatory tissue). The comparisons were made only between the same joints, and the arthritis was of identical duration. Erosions were observed in almost 100% of the PIP joints from the control groups and in approximately 70-80% of the joints given either anti-CD4 lone or sub-optimal anti-THF alone. The results of the two experiments were pooled, and are shown in Table 2.

TABLE 2

Proportions of PIP joints showing Significant
Erosion of Cartilage and/or Bone

	Treatment	Joints with Erosions

Sub-optimal anti-TNF (50 μg)

	Anti-CD4	13/18 (72%)
	Anti-TNF	14/19 (74%)
	Anti-CD4/TNF	4/18 (22%)¹
	Control mAb	17/18 (94%)

Optimal anti-TNF (300 μg)

	Anti-CD4	10/12 (83%)
	Anti-TNF	6/11 (54%)²
	Anti-CD4/TNF	4/13 (31%)³
	Control mAb	12/12 (100%)

¹P < 0.01 (anti-CD4/TNF vs. anti-CD4 alone; antiTNF alone and control mAb)
²P < 0.01 (antiTNF alone vs. control mAb)
³P < 0.01 (antiCD4/TNF vs. antiCD4 alone and control mAb)

An optimal dose of anti-TNF alone significantly reduced pathology, as reported previously (Williams, R. O. et al., PNAS 89: 9784-9788 (1992)). Thus, in the mice given optimal anti-TNF alone the proportion of joints showing erosive changes was reduced to 54% (P<0.001) whereas in the groups given anti-CD4 plus either sub-optimal or optimal anti-TNF, only 22% (P<0.01) and 31% (P>0.01) of the joints, respectively, were eroded. Thus, 300 .mu.g of anti-TNF alone gave a degree of protection against joint erosion but combined anti-CD4/anti-TNF provided significantly greater protection.

Example 2

Treatment of Induced Arthritis in a Murine Model using TNF Receptor/IgG Fusion Protein with Anti-CD4 Antibody

The murine model of collagen type II induced arthritis, described above, was used to investigate the efficacy of a human p55 TNF receptor/IgG fusion protein, in conjunction with anti-CD4 monoclonal antibody (mAb), for its ability to modulate the severity of joint disease in collagen-induced arthritis. First, a comparison was made between the efficacy of TNF receptor/IgG fusion protein treatment, anti-TNF mAb treatment, and high dose corticosteroid therapy. Subsequently, therapy with TNF receptor/IgG fusion protein in conjunction with anti-CD4 antibody was investigated.

A. Experimental Procedure

Male DBA/1 mice were immunized intradermally with 100 .mu.g of bovine type II collagen emulsified in complete Freund's adjuvant (Difco Laboratories, East Molsey, UK). The mean day of onset of arthritis was approximately one month after immunization. After the onset of clinically evident arthritis (erythema and/or swelling), mice were injected intraperitoneally with therapeutic agents. Arthritis was monitored for clinical score and paw swelling (measured with calipers) for 10 days, after which the mice were sacrificed and joints were processed for histology. Sera were collected for analysis on day 10. Therapeutic agents were administered on day 1 (onset), day 4 and day 7. The therapeutic agents included TNF receptor/IgG fusion protein (p55-sf2), anti-TNF antibody, anti-CD4 antibody, and methylprednisolone acetate.
B. Comparison of Treatment with TNF Receptor/IgG Fusion Protein, Anti-TNF Antibody, or Methylprednisolone Acetate
Using the Experimental Procedure described above, groups of mice were subjected to treatment with TNF receptor/IgG protein (2 μg) (18 mice), TNF receptor/IgG protein (20 μg) (18 mice), TNF receptor/IgG protein (100 μg) (12 mice), anti-TNF monoclonal antibody (mAb) (300 μg) (17 mice), methylprednisolone acetate (6 mice), an irrelevant human IgG1 monoclonal antibody (mAb) (6 mice), or saline (control). The TNF receptor/IgG fusion protein, herein referred to as p55-sf2, (Butler et al., Cytokine (in press): (1994), was provided by Centocor, Inc., Malvern Pa.; it is dimeric and consists of the human p55 TNF receptor (extracellular domains) fused to a partial J sequence followed by the whole of the constant region of the human IgG1 heavy chain, itself associated with the constant region of a kappa light chain. The anti-TNP antibody was TN3-19.12, a neutralizing hamster IgG1 anti-TNFα/β monoclonal antibody (Sheehan, K. C. et al., J. Immunology 142:3884-3893 (1989)), and was provided by R. Schreiber, Washington University Medical School (St. Louis, Mo., USA), in conjunction with Celltech (Slough, UK). Neutralizing titres were defined as the concentration of TNF.alpha. neutralizing agent required to cause 50% inhibition of killing of WEHI 164 cells by trimeric recombinant murine TNF.alpha.; the neutralizing titre of p55-sf2 was 0.6 ng/ml, compared with 62.0 ng/ml for anti-TNF mAb (TN3-19.12), using 60 pg/ml mouse TNFα. The corticosteroid, mathyl-prednisolone acetate (Upjohn, Crawley, UK) was administered by intraperitoneal injection as an aqueous suspension at a dosage level of 2 mg/kg body weight; using the protocol described above, this dosage is equivalent to 4.2 mg/kg/week, a dose which is higher than the typical dose used to treat refractory RA in humans (1-2 mg/kg/week).

Paw-Swelling

Treatment with p55-sf2 resulted in a dose-dependent reduction in paw-swelling over the treatment period, with the doses of 20 μg and 100 μg giving statistically significant reductions in paw-swelling relative to mice given saline (P<0.05). The group of mice given an irrelevant human IgG1 mAb as a control did not show any deviation from the saline-treated group (data not shown), indicating that the therapeutic effects of p55-sf2 were attributable to the TNF receptor rather than the human IgG1 constant region. Similar reductions in paw-swelling were seen in mice given 300 μg of anti-TNF mAb as in those given 100 μg of p55-sf2, although anti-TNF mAb was marginally more effective than p55-sf2 at inhibiting paw-swelling. A reduction in paw-swelling was observed in the methylprednisolone acetate treated group that was comparable in magnitude to the reductions given p55-sf2 at 100 μg or anti-TNF mAb at 300 μg.

Limb Involvement

The change in the number of arthritic limbs over the 10 day treatment period was examined. Results are shown in Table 5.

TABLE 5

Inhibitory Effect of TNF-Targeted Therapy on Limb Recruitment

	Limbs Affected
Treatment	(mean ± SEM)

(number of animals)	Day 1	Day 10	Increase (%)

Saline (n = 12)	1.33 ± 0.14	2.25 ± 0.18	69%
P55-sf2,	1.28 ± 0.11	1.94 ± 0.17	51%
2 μg (n = 18)
P55-sf2,	1.37 ± 0.11	1.79 ± 0.16	31%
20 μg (n = 18)
P55-sf2,	1.17 ± 0.17	1.58 ± 0.23	35%
100 μg (n = 12)
Control IgG1,	1.00 ± 0.00	1.15 ± 0.22	50%
100 μg (n = 6)
Anti-TNF mAb,	1.47 ± 0.15	1.76 ± 0.16¹	20%
300 μg (n = 17)
Methylpresnisolone	1.00 ± 0.00	1.50 ± 0.22	33%
Acetate (n = 6)

P, 0.05 (vs. saline; Mann Whitney Test)

A strong trend towards reduced limb recruitment was seen in the groups of mice given p55-sf2, anti-TNF mAb or methylprednisolone acetate, but only in the anti-TNF mAb treated group did the reduction reach statistical significance (P<0.05).

Histology

After 10 days, the mice were sacrificed; the first limb to show clinical evidence of arthritis was removed from each mouse, fixed, decalcified, wax-embedded, and sectioned and stained with haematoxylon and eosin. Saggital sections of the proximal interphalangeal (PIP) joint of the middle digit of each mouse were studied in a blind fashion and classified according to the presence or absence of erosions, as defined above. Comparisons were thus made between identical joints, and the arthritis was of equal duration. Results are shown in Table 6.

TABLE 6

Histopathology of PIP Joints

	Treatment	PIP Joints with Erosions

	Saline
	11/12 (92%)
	P55-sf2, 2 μg	14/18 (78%)
	P55-sf2, 20 μg	14/18 (78%)
	P55-sf2, 100 μg	6/12 (50%)
	Control IgG1, 100 μg	6/6 (100%)
	Anti-TNF mAb, 300 μg	7/17 (41%)
	Methylpresnisolone acetate	4/6 (67%)

P < 0.05 (vs. saline).
P < 0.01 (vs. saline). Data were compared by Chi-square analysis.

Erosions were present in 92% and 100% of the PIP joints in the saline treated group and the control human IgG1 treated group, respectively. However, only 50% (P<0.05) of joints from the mice treated with p55-sf2 (100 μg) and 41% (P<0.01) of mice given anti-TNF mAb exhibited erosive changes. Some reductions in the proportion of eroded joints were observed in mice treated with 2 μg or 20 μg of p55-sf2, but these were not statistically significant. Similarly, treatment with methylprednisolone acetate did not significantly reduce joint erosion.

Example 3

Treatment of Induced Arthritis in a Murine Model using Cyclosporin A and Anti-TNF Antibody

The murine model of collagen type II induced arthritis, described above, was used to investigate the efficacy of the CD4+ T cell inhibiting agent cyclosporin A in conjunction with anti-TNF monoclonal antibody (mAb), for the ability to modulate the severity of joint disease in collagen-induced arthritis. A comparison was made between the efficacy of treatment with cyclosporin A (CsA), anti-TIF antibody, and combination of CSA and anti-TNF antibody.
A. Experimental Procedure
Male DBA/1 mice were immunized intradermally with 100 μg of bovine type II collagen emulsified in complete Freund's adjuvant (Difco Laboratories, East Molsey, UK). The mean day of onset of arthritis was approximately one month after immunization. After the onset of clinically evident arthritis (erythema and/or swelling), groups of mice (11 mice each) were subjected to treatment with one of the following therapies: 50 μg (2 ag/kg) L2 (the isotype control for anti-TNF antibody), intraperitoneally once every three days ( days 1, 4 and 7); 250 μg (10 mg/kg) cyclosporin A intraperitoneally daily; 50 μg (2 mg/kg) anti-TNF mAb TN3-19.12, intraperitoneally once every three days ( days 1, 4 and 7); or 250 μg cyclosporin A intraperitoneally daily in conjunction with 50 .mu.g anti-TNF mAb intraperitoneally once every three days. Arthritis was monitored for paw swelling (measured with calipers) for 10 days, after which the mice were sacrificed and joints were processed for histology.
Paw-Swelling
Treatment with cyclosporin A in conjunction with anti-TNF mAb resulted in a reduction in paw-swelling over the treatment period, relative to mice treated with control antibody. Results are shown in FIG. 3.
Limb Involvement
As before, the progressive involvement of additional limbs following the initial appearance of arthritis was studied. Results are shown in Table 10.

TABLE 10

Anti-CD4 Antibody and p55-sf2 Prevent New Limb Recruitment

	Limbs Affected
	(mean ± SEM)

Treatment	Day	1	Day 10	Increase (%)

Control mAb	1.36 ± 0.20	2.45 ± 0.28	80.1%
Cyclosporin A	1.36 ± 0.15	2.18 ± 0.30	60.3%
Anti-TNF mAb	1.45 ± 0.16	1.9 ± 0.21	31.0%
CsA/Anti-TNF mAb	1.27 ± 0.14	1.54 ± 0.21¹	21.0%

P = 0.03 (vs. control).

Treatment with cyclosporin A in conjunction with anti-TNF mAb resulted in statistically significant reductions in limb involvement in comparison to control monoclonal antibody (P=0.03).

Example 5

Treatment of Induced Arthritis in a Murine Model using Anti-TNF Antibody and a Sub-Optimal Dose of Cyclosporin A

The murine model of collagen Type II induced arthritis, described above, was used to investigate the ability of cyclosporine A to prolong the therapeutic effect of a single injection of anti-TNF antibody to modulate the severity of join t disease in collagen-induced arthritis. A comparison was made between the efficacy of treatment with a single injection of 300 μg anti-TNF antibody alone, and a combination of a single injection of 300 μg anti-TNF antibody and a sub-optimal dose of CsA.

Experimental Procedure

Male DBA/1 mice were immunized intradermally with 100 μg of bovine type II collagen emulsified in complete Freund's adjuvant (Difco Laboratories, East Molsey, UK). The mean day of onset of arthritis was approximately one month after immunization. After the onset of clinically evident arthritis (erythema and/or swelling in one or more limbs), three groups of mice (10 mice per group) were subjected to treatment with one of the following therapies: 250 μg (10 mg/kg) cyclosporine A (Sandoz Pharmaceuticals, East Hanover, N.J.), injected intra-peritoneally in conjunction with 300 μg (12 mg.kg) anti-TNF mAb, injected intra-peritoneally, on day one; or 300 μg anti-TNF mAb TN3-19.12, injected intra-peritoneally on day one. Arthritis was monitored for paw swelling (measured with calipers) for 10 days, after which the mice were sacrificed and joints were processed for histology.

Paw-Swelling

Paw swelling was monitored as described in Example 4. Treatment with a sub-optimal dose of cyclosporine A in conjunction with a single injection of anti-TNF mAb (300 μg) resulted in a sustained reduction in paw-swelling over the treatment period, relative to mice treated with a sub-optimal dose of CsA in conjunction with the control antibody and mice treated with 300 μg anti-TNF mAb alone. Results are shown in FIG. 6.

Histology

Saggital sections of the PIP joint of the middle digit of each mouse (from the first paw with clinical arthritis) were examined in a blind fashion by microscopy and classified according to the presence or absence of erosions, using the procedure described in Example 1. Comparisons were thus made between identical joints, and the arthritis was of equal duration. Results are shown in Table 11.
TABLE 11

PIP Joint Erosions

Treatment Incidence of Erosions

L2/CsA 8/10 (80%)

TN3 alone 8/9 (89%)

CsA/TN3 6/10 (60%)

In mice given a sub-optimal dose of CsA in conjunction with 300 μg of anti-TNF mAb, the proportion of joints showing erosive changes was reduced to 60% whereas, in the group of mice given a sub-optimal dose of CsA plus control antibody, 80% of the joints were eroded, and in the group of mice given 300 μg anti-TNF mAb, 89% of the joints were eroded. Thus, treatment with a sub-optimal dose of CsA in conjunction with 300 μg anti-TNF mAb provided a degree of protection against joint erosion.

Example 6

Treatment of Induced Arthritis in a Murine Model using Cyclosporin A and Anti-TNF Antibody at Effective Doses

Using the murine model of collagen type II induced arthritis, described above, a comparison was made between the efficacy of treatment with CsA alone, anti-TNF antibody, for the ability to modulate the severity of joint disease in collagen induced arthritis.
Experimental Procedure
Male DBA/1 mice were immunized intradermally with 100 μg of bovine type II collagen emulsified in complete Freund's adjuvant (Difco Laboratories, East Molsey, UK). The mean day of onset of arthritis was approximately one month after immunization. After the onset of clinically evident arthritis (erythema and/or swelling in one or more limbs), three groups of mice (11-12 mice per group) were subjected to treatment with one of the following therapies: 500 μg (20 mg/kg) cyclosporin A (SANDIMMUNE®, Sandoz Pharmaceuticals, East Hanover, N.J.), injected intra-peritoneally daily; 250 μg (10 mg/kg) anti-TNF mAb TN3-19.12, injected intra-peritoneally once every three days ( days 1, 4, and 7); or 500 μg cyclosporine A, injected intra-peritoneally daily in conjunction with 250 μg anti-TNF mAb, injected intra-peritoneally once every three days. A control group of 24 mice was administered PBS, injected intra-peritoneally daily, after the onset of clinically evident arthritis. Arthritis was monitored for paw swelling (measured with calipers) for 10 days, after which the mice were sacrificed and joints were processed for histology.
Clinical Score
Clinical score was assessed on the following scale: 0=normal; 1=slight swelling and/or erythema; 2=pronounced edematous swelling; and 3=joint rigidity. Each limb was graded, giving a maximum score of 12 per mouse.
The results are presented in FIG. 7 and show that treatment with 500 μg cyclosporine A plus 250 μg anti-TNF mAb resulted in a significant reduction in the severity of arthritis over the treatment period, relative to the control group (PBS treated group). Treatment with either 250 μg anti-TNF mAb alone of 500 μg cyclosporine A alone also reduced the severity of arthritis. (P<0.05 and related to differences between the PBS treated group (Mann-Whitney U Test).

Histology

For histology, the mice were sacrificed 10 days and the first limb that had shown clinical evidence of arthritis was removed from each mouse, formalin-fixed, decalcified, and waz-embedded before ectioning and staining with haematoxlon and eosin. A saggital section of the proximal interphalangeal (PIP) joint of the middle digit was examined by microscopy in a blind fashion for the presence or absence of erosions in either cartilage or bone (defined as demarcated defects in cartilage or bone filled with inflammatory tissue). Comparisons were made between the same joints, and the arthritis was of identical duration. Erosions were observed in 9% of the POP joints from the group of mice treated with a combination of 500 μg (20 mg/kg) CsA and 250 μg (10 mg/kg) anti-TNF mAb compared with in 36% of the PIP joints from the group of mice treated with 500 μg CsA alone and 42% of the PIP joints from the group of mice treated with 250 μg anti-TNF antibody alone. The results of the experiment are shown in Table 13.

TABLE 13

Therapeutice Effects of Cyclosporin A and Anti-TNF
Monoclonal Antibody in Established Collagen-Induced Arthritis

	No.	Histology: proportion of
Treatment	mice per group	PIP joints with erosions

PBS
	24	23/24 (96%)
CsA (20 mg/kg)	12	4/11 (36%)
		(P < 0.001)
Anti-TNF mAb (10 mg/kg)	12	5/12 (42%)
		(P < 0.001)
CsA (20 mg/kg) plus	11	1/11 (9%)
Anti-TNF mAb (10 mg/kg)		(P < 0.001)

P values refer to comparisions with the PBS-treated group.

Treatment with cyclosporine A in conjunction with anti-TNF antibody provides a greater degree of protection against arthritis than treatment with either reagent alone. The results show that there is an additive or synergistic ameliorative effect between cyclosporine A and anti-TNF antibody.

Example X

Specificity of an Anti-TNF Chimeric Antibody

Since the antigen binding domain of cA2 was derived from murine A2, these mAbs would be expected to compete for the same binding site on TNF. Fixed concentrations of chimeric A2 and murine mAb A2 were incubated with increasing concentrations of murine and chimeric A2 competitor, respectively, in a 96-well microtiter plate coated with rhTNF (Dainippon, Osaka, Japan). Alkaline-phosphatase conjugated anti-human immunoglobulin and anti-mouse immunoglobulin second antibodies were used to detect the level of binding of chimeric and murine A2, respectively. Cross-competition for TNF antigen was observed in this solid-phase ELISA format (FIG. 9). This finding is consistent with the expected identical epitope specificity of cA2 and murine A2.
The affinity constant for binding of mouse mAb A2 and cA2 to rhTNF.alpha. was determined by Scatchard analysis (see, for example, Scatchard, Ann. N.Y. Acad. Sci. 51:660 (1949)). The results are shown in FIG. 10. This analysis involved measuring the direct binding of ¹²⁵I labelled cA2 to immobilized rhTNFα in a 96-well plate. The antibodies were each labelled to a specific activity of about 9.7 μCi/μg by the iodogen method. An affinity constant (Ka) of 0.5×10⁹liters/mole was calculated for the mouse mAb A2. Unexpectedly, the chimeric A2 antibody had a higher affinity, with a Ka of 1.8×10⁹liters/mole. Thus, the chimeric anti-TNFα antibody of the present invention was shown to exhibit a significantly higher affinity of binding to human TNFα than did the parental murine A2 mAb. This finding was surprising, since murine and chimeric antibodies, fragments and regions would be expected to have affinities that are equal to or less than that of the parent mAb.
Such high affinity anti-TNF antibodies, having affinities of binding to TNFα of at least 1×10⁸M⁻¹, more preferably at least 1×10⁹M⁻¹(expressed as Ka) are preferred for immunoassays which detect very low levels of TNF in biological fluids. In addition, anti-TNF antibodies having such high affinities are preferred for therapy of TNF-α-mediated conditions or pathology states.
The specificity of cA2 for TNF was confirmed by testing for cross-neutralization of human lymphotoxin (TNF-β). Lymphotoxin shares some sequence homology and certain biological activities, for example, tumor cell cytotoxicity, with TNF (Pennica, et al., Nature 312:724-729 (1984)). Cultured human A673 cells were incubated with increasing concentrations of human lymphotoxin (GENENTECH, San Francisco, Calif.) with or without 4 μg/ml chimeric A2 in the presence of 20 μg/ml cycloheximide at 39° C. overnight. Cell death was measured by vital staining with naphthol blue-black, as above. The results indicated that cA2 was ineffective at inhibiting and/or neutralizing human lymphotoxin, confirming the TNFα-specificity of the chimeric antibody.
The ability of A2 or cA2 to react with TNF from different animal species was also evaluated. As mentioned earlier, there are multiple epitopes on human TNF to which inhibiting and/or neutralizing mAbs will bind (Moller, et al., infra). Human TNF has bioactivity in a wide range of host animal species. However, certain inhibiting and/or neutralizing epitopes on human TNF are conserved amongst different animal species and others appear to be restricted to humans and chimpanzees.
Neutralization experiments utilized endotoxin-activated cell supernatants from freshly isolated human, chimpanzee, rhesus and cynomolgus monkey, baboon, pig, dog, rabbit, or rat monocytes as the TNF source. As discussed above, murine mAb A2 inhibited or neutralized activity of only human and chimpanzee TNF, and had no effect on TNF derived from other primates and lower animals. A2 also did not inhibit or neutralize the cytotoxic effect of recombinant mouse TNF.
Thus, the epitope recognized by A2 is one shared by human and chimpanzee TNFα. Chimeric A2 was also tested in this manner for cross-reactivity with monocyte-derived TNF from rat, rabbit, dog and pig, as well as with purified recombinant mouse TNFα, and natural and recombinant human TNFα. Chimeric A2 only inhibited or neutralized natural and recombinant human TNFα. Therefore, cA2 appears to share species specificity with murine A2.

Example XX

Clinical Treatment of Rheumatoid Arthritis by a Anti-TNF Antibody or Peptide of the Present Invention

A Phase I open label study was conducted for methods and compositions of the present invention using a chimeric anti-TNF MAb for the treatment of patients with severe refractory rheumatoid arthritis. Nine patients were enrolled in the study. The first five patients were treated with chimeric anti-TNF antibody (cA2), 10 mg/kg as a single dose infused over a period of two hours. These patients were subsequently retreated with a second infusion of 10 mg/kg on day 14 of the study. The second group of five patients received an infusion of 5 mg/kg on the first day of the study. They were then treated with additional infusions of 5 mg/kg on days 5, 9, and 13. Four of the planned five patients in this second group have been treated to date.
Preparation, Administration, and Storage of Test Material The chimeric monoclonal anti-TNF antibody was supplied in single-use glass vials containing 20 mL with 100 mg of anti-TNF (5 mg/mL). The anti-TNF antibody was stored at 2-8.degree. C. Prior to infusion, the antibody was withdrawn from the vials and filtered through a low-protein-binding 0.22 .mu.m filter. This filtered antibody was then diluted to a final volume of 300 mL with normal saline. The 300 mL antibody preparation was then infused via an in-line filter over a period of not less than two hours.
Prior to each repeat infusion of study medication a test dose of 0.1 mL of the infusion was diluted in 10 mL of normal saline and administered by slow IV push over 5 minutes. The patient was observed for 15 minutes for signs or symptoms of an immediate hypersensitivity reaction. If no reaction was observed in this time period, the full dose was administered as described above.
Administration Protocol
Group 1 (patients 1-5): a total of 2 infusions, on day 1 and day 15 of the trial; dosage 10 mg/kg on each occasion; Group 2 (patients 6-9): a total of 4 infusions, on days 1, 5, and 13 of the trial; dosage 5 mg/kg on each occasion.
All infusions were administered iv over 2 hours in a total volume of cA2+saline of 300 ml. Infusions subsequent to the first in any patient were preceded by a small test dose administered as an iv push. All patients had at least three years of disease activity with rheumatoid arthritis. The patients ranged in age from 23 to 63. All patients had failed therapy with at least three different DMARD (Disease Modifying Anti-Rheumatic Drug). Six of the nine patients had serum rheumatoid factors, and all nine patients had erosions present on X-rays.

Clinical Monitoring

Patients were monitored during and for 24 hours after infusions for hemodynamic change, fever or other adverse events. Clinical and laboratory monitoring for possible adverse events was undertaken on each follow-up assessment day. Clinical response parameters were performed at the time-points as specified in the flow charts present in Tables 9A and 9B. These evaluations were performed prior to receiving any infusions.

- Clinical response studies will be comprised of the following parameters:
- 1. Number of tender joints and assessment of pain/tenderness:
- The following scoring will be used:
  - 0=No pain/tenderness
  - 1=Mild pain. The patient says it is tender upon questioning. 2=Moderate pain. The patient says it is tender and winces. 3=Severe pain. The patient says it is tender and winces and withdraws.
- 2. Number of swollen joints
  - Both tenderness and swelling will be evaluated for each joint separately. MCP's, PIP's etc. will not be considered as one joint for the evaluation.
- 3. Duration of morning stiffness (in minutes)
- 4. Grip strength
- 5. Visual analog pain scale (0-10 cm)
- 6. Patients and blinded evaluators will be asked to assess the clinical response to the drug. Clinical response will be assessed using a subjective scoring system as follows:
  - 5=Excellent response (best possible anticipated response)
  - 4=Good response (less than best possible anticipated response)
  - 3=Fair response (definite improvement but could be better)
  - 2=No response (no effect)
  - 1=Worsening (disease worse)
- Measurement of index of disease activity is scored according to the following Table 5.

TABLE 5

Clinical Characteristics of Patients 1-5

					Previous
		Di			T
Pa	Age/	Duration	Rhe		(DMA
Number	Sex	(years)	Fac	Nodules	only)	Therapy

01	48/F	7		−ve/	*Sal, DP, Myo,	**Pred 5
					, MTX,
					, Chl
02		7	−ve	+ −ve	l, M o, DP	Para 1-2 g
		3	+ve	+ −ve	, C l, My ,
					MTX, S l	225 mg
04	56/M	10	+ve	−ve	My , DP, A ,	12.5 mg,
					Sal	2 g,
						Para 1-2
05	28/F	3		−ve	M , Sal, DP,	P 8 mg,
					A	Para 1-2 ,
						Cod 16

*Sal = ; DP = D- ; Myo = Myo ; Aur = ; MTX = m ; A = ; Ch = .
**P = ; P = p ; d = indo ; = ; C = .
indicates data missing or illegible when filed

TABLE 6

Cli cal Characteristics of P

					Previous
		D			Tre	C
P	Age/	Dura	Rhe	Er	(DMARDs
Number	Sex	(y s)	Fact	N	)	Therapy

06	M	3		**Nap 1 g
07	F	7	DP, Myo, Sal,	Para 1-2 g
			A , MTX	Oxl 16- mg
08	F	11	Chl, Myo, Sal,	Pred 7.5 mg, Dicl
			MTX, A	100 mg, Para 1-2 g,
				Dext 100-200 mg
09	F	15	Myo, Chl, DP,	Pred 7.5 mg, Dicl
			MTX	125 mg, Para 1-3 g

*Sal = ; Chl = ; A = ; D = D- ; M = My ; A = ; MTX = .
**N = ; P = ; Cod = ; P = ; D = dicl ; De = de .
indicates data missing or illegible when filed

TABLE 7

		Pa	Number	Rit	ip	CRP
	M	(10-10		A	Strength		IDA
				Index	L/R ;	normal
Number	(m )	VAS)	(0-28)	(0- )		< 10)	1- )

01	60	3.	19	30		33	5
02	20	2.	25	31		18	14	.0
03		4.	14	16	230/238	48	44	.5
04	30	6.	17	12	204/223	24	35	2.33
05		5.	28	41	52/	87	107	3.0

indicates data missing or illegible when filed

TABLE 8

Disease Activity at Entry for Patients 6-9

		Pain			Grip	ESR	CRP
	Morning	(0-10			S h	(mm	(mg	IDA
P	Stiffness	cm			L/R (mm/Hg;	ranges: F <
Number	(mins)	VAS)	(0-2 )	(0- )	)	M < )		1-4)

06	120	5.0	3	4		23	3
07	105	7.	27	31		25	10	2.83
08	270	.3	17	37	73/125	35	31	3.17
09	180	.5	20	26	5 75	15		.5

indicates data missing or illegible when filed

All patients have tolerated the infusions of chimeric anti-CD4 and no serious adverse reactions have been observed. Specifically, no episodes of hemodynamic instability, fevers, or allergic reactions were observed in association with the infusions. Patients have not experienced any infections.
Although this is a non-blinded study, all patients experienced improvement in their clinical assessments of disease status, as well in biochemical parameters of inflammation measured in their serum.
Clinical assessments, including the duration of early morning stiffness; the assessment of pain on a visual analogue scale; total count of swollen joints; Ritchie articular index (a scaled score which assesses the total number of tender joints and the degree of joint tenderness); and Index of Disease Activity (a scaled score which incorporates several clinical and laboratory parameters), showed impressive improvements compared to controls. These improvements were typically in the range of an 80% drop from the baseline score; a degree of improvement which is well beyond the amount of improvement that can be attributed to placebo response. In addition, the duration of these improvements was for six to eight weeks in most cases, a duration of response far longer than would be anticipated from a placebo.
The improvements in clinical assessments were corroborated by improvements in biochemical inflammatory parameters measured in serum. The patients showed rapid drops of serum C-reactive protein, usually in the range of 80% from the baseline. Reductions in the erythrocyte sedimentation rate, usually in the range of 40%, were also observed. Circulating soluble TNF receptors were also decreased following therapy. The durations of the biochemical responses were similar to the duration of the clinical responses.
Preliminary assessment of immune responses to the chimeric anti-TNF antibody has shown no antibody response in the first four patients.
In summary, the preliminary evaluation of the results of this Phase I trial indicate that treatment of patients with advanced rheumatoid arthritis with anti-TNF MAb of the present invention is well tolerated and anti-TNF treatment is associated with rapid and marked improvement in clinical parameters of disease activity, including early morning stiffness, pain, and a number of tender and swollen joints; and is accompanied by improvement of biochemical parameters of inflammation.
Although this was an open label study, the magnitude of the clinical improvements is well beyond the degree of improvement that would be anticipated from a placebo response, such that the present invention is shown to have significant clinical efficacy for treating rheumatoid arthritis.

TABLE 9A

Study TRA
Group I day 1 and day 14)

	Pre-	Screen-	Wk 0	Wk 0		Wk 2
	Scr	ing	D 1	D 2	Wk 1	D 14	Wk 3	Wk 4	Wk 6	Wk 8

C	X
D		X
Physical		X								X
Ex
Pregnancy		X
Test
Weight		X	X			X				X
Signs		X	X*	X	X	X*	X	X	X	X
			X			X

		X	X′	X	X	X′	X	X	X	X

Clinical				X	X	X′	X	X	X	X
(Safety)
Clinical		X	X′		X	X′	X	X	X	X
(Response)
		X			X7

Response										X
Evaluation

He	X	X′		X	X′	X	X	X	X

Biochemistry	X	X′		X	X′	X	X	X	X
Urinalysis		X′		X	X′	X	X	X	X
		X′		X	X′	X	X	X	X
		X′		X	X′	X	X	X	X
PBL		X	X	X
Pharma		X^#	X^#		X^$
HACA Response		X′		X	X′	X	X	X	X

X = Vital signs will be obtained , every 30 minutes and every 30 minutes for 2 hours after the infusion;
X = Needs to be done prior to the
X = Serum samples will be obtained prior to the infusion and 1, 2, 4, 8, 12, and 24 after the end of the ;
X = Serum samples be obtained to the at 2 hours after the end of the .
indicates data missing or illegible when filed

TABLE 9B

Flowchart for Chimeric Anti-TNF Study C0168TRA Group II2 ( every day 4 times total)

Pre-

Screen-

Wk 0

Wk 1

Scr

ing

D 1

D 2

D 5

D 9

D 13

Wk 2

Wk 3

Wk 4

Wk 6

Wk 8

X

Physical

X

Examination

Pregnancy

X

Test

Weight

X

Vital Signs

X

X*

X

X*

X

Anti-TNF

X

Labs,

X

X′

X

X′

X

Chart

Cl

X

X′

X

(

)

Clinical

X

X′

X

(Response)

X

X7

Response

X

Evaluation

+

X

X′

X

ESR

Biochemistry

X

X′

X

Urinalysis

X′

X

CRP + RF

X′

X

X′

X

PBL

X

Pharmacokinetic

X

X^$

Response

X′

X

= Vital signs will be obtained prior to infusion, every 30 minutes during the infusion and every 30 minutes for 2 hours after the infusion;

X

= Needs to be

prior to the infusion;

X

= Serum samples will be obtained prior to the

and at 1, 2, 4, 8, 12, and 24 hours after the end of the infusion;

X

= Serum samples

be obtained to the infusion and at 2 hours

end of the infusion.

indicates data missing or illegible when filed

TABLE 10

Measurement of the of Disease Activity (DA) Variables of Di Activity

M

Grip

IDA

Stiffness

Pain

Score	(min)	( , cm)*	(mm )	Index	Male	Female

1	<10	0-2.4		0	>14.1	1.7	0.20
2	10-30	2.5-4.4	50-200	1-	13-14	10.8-11.6	21-45
3	31-120	4.5-6.4	30-49	8-17	10-12.9		46-80
4	>120	6.5-10	<30		<9.9	<8.3

*Pain was measured on a visual 0-10 cm.
indicates data missing or illegible when filed

Conclusions (1)

- Safety of anti-TNF in RA
- Anti-TNF was safe and very well tolerated:
- no hemodynamic, febrile or allergic episodes;
- no infections;
- no clinical adverse events;
- a single laboratory adverse event only, probably unrelated to anti-TNF.
- Conclusions (2)
- Efficacy of anti-TNF in RA Anti-TNF therapy resulted in:
  - rapid and marked improvements in EMS, pain and articular index in most patients;
  - slower but marked improvement in swollen joint score, maximal by 3-4 weeks;
  - rapid and impressive falls in serum CRP, and a slower fall in ESR;
  - normalization of CRP and ESR in some patients;
  - rapid falls in serum C4d (a complement breakdown product) and IL-6 in patients where these indices were elevated at entry.
- Duration of clinical improvements variable, with rebound in some patients at 6-8 weeks.

Accordingly, the present invention has been shown to have clinical efficacy in human patients for treating TNF involved pathologies using TNF MAbs of the present invention, such as for treating rheumatoid arthritis. Additionally, the human clinical use of TNF antibodies of the present invention in humans is also shown to correlate with in vitro data and in vivo animal data for the use of anti-TNF antibodies of the present invention for treating TNF-related pathologies.

Example XXII

Treatment of Arthritis in Humans using Chimeric Immunoglobulin Chain of the Present Invention

Patient Selection
Twenty patients were recruited, each of whom fulfilled the revised American Rheumatism Association criteria for the diagnosis of RA (Arnett et al., Arthritis Rheum. 31:315-324 (1988). The clinical characteristics of the patients are shown in Table 12. The study group comprised 15 females and 5 males, with a median age of 51 years (range 23-72), a median disease duration of 10.5 years (range 3-20) and a history of failed therapy with standard disease-modifying anti-rheumatic drugs (DMARDs; median number of failed DMARDs: 4, range 2-7). Seventeen were seropositive at entry or had been seropositive at some stage of their disease, all had erosions on X-Rays of hands or feet, and 3 had rheumatoid nodules. All patients had active disease at trial entry, as defined by an Index of Disease Activity (IDA; Mallya et al., Rheumatol. Rehab. 20:14-17 (1981) of at least 1.75, together with at least 3 swollen joints, and were classed as anatomical and functional activity stage 2 or 3′ (Steinbrocker et al., JAMA 140:659-662 (1949). The pooled data for each of the clinical and laboratory indices of disease activity at the time of screening for the trial (up to 4 weeks prior to trial entry), and on the day of trial entry itself (week 0), are shown in Tables 13 and 14.

TABLE 12

Demographic Features of Falis with Refr Elc Arthritis

	Age/	DD
P	Sex	(yr)	Previous DMARDs	C tant therapy

1	41/F	7	SSZ, DP, GST, AUB_MTX,	Pred 5 mg
			AZA, HCQ
2	63/F	7	SSZ, GST, DP	Pred 1-2 g
3	/M	3	AUR, HCQ, GST,	Pred 10 mg; 225 mg
			MTX, SSZ
4	56/M	10	GST, DP, AZA, SSZ	Pred 12.5 mg; 5 g; 1-2 g
5		3	GST, SSZ, DP, AZA	Pred	1 mg; Para 1-2 g; Cod 16 mg
6	/M	3	SSZ, HCQ, AUR	1 g
7	54/F	3	DP, GST, SSZ,	Pred 1-2 g; Cod 16-32 mg
			AZA, MTX
8	/F	11	HCQ, GST, SSZ,	P d 1.5 mg; Diel 1( ) mg; Para
			MTX, AZA	1-1 g; -20 mg
9	/F	15	GST, HCQ, DP, MTX	Pred 1.5 mg, Diel 123 mg; Para
				1-3 g
10	41/F	12	SSZ, CYC, MTX	4 g
11	54/F	10	DP, SSZ, MTX	Pred	10 mg; Para 1-5 g; COD 30-93 mg
12	5 /F	12	GST, MTX, TXP, AUR	Axp 1-2 g
13	51/F	3	SSZ, AZA	Para 1-4
14	M	11	GST, DP, AZA, MTX	Pred	5 mg; Para 1-4 g; C 16-63 mg
15	56/F		HCQ, DP, SSZ, MTX	A 0.3 g
16	62/F	16	GST, DP, SSZ,	Para 1-4 g; Cod 16-64 mg
			MTX, AZA
17	46/F	13	SSZ, DP, GST,	Pred 1.5 mg; 600 mg; Para
			MTX, HCQ, AZA	1-2 g; Dex 100-200 mg
18	/F	14	GST, MTX, DP, SS,	Pred 7.5 mg; 100 mg; Para
			ZAUR, AZA	1-3 g
19	42/F	3	SSZ, MTX	Feu 450 mg; B 6 g; Cod 50 mg
20	47/M	20	GST, DP, SSZ, AZA	Pred	10 mg; Para 1-3 g

Pat = Patient;
DD (yrs) = Disease duration (years);
DMARDs = disease-modifying anti-thematic drugs;
SSZ = ;
DP = D-pa ;
GST = gird th ;
AUR = ;
MTX = metiaxtre ;
AZA = ;
HCQ = (hy ) ;
CYC = cyclophosph ;
Pred = pre ( );
Para = pretreatment;
I = ;
Ibn = i ;
Cod = codeine p ;
Nrp = ;
Diel = diele ;
= ;
Bet = bes ;
Axp = rin;
etp = eto ;
Feu = fre ;
indicates data missing or illegible when filed

TABLE 13

Changes in Clinical Assessments Following Treatment of Rheumatoid Arthritis Patients with cA2

								Pa
		Pain		Swollen	Strength	Strength
	Morning	Score		Joints	(L)	(R)		(grades
of	Stiffness	(0-10)	Index	(0-28)	(0- )	(0-30 )	IDA	improved
Trial	( )	cm	(0-69)		mm Hg	mm Hg	(1-4)	0-3)

Screen	135	7.4	23	16	84		3	NA
	(0-600)	(4- )	(4-51)	(4- 8)	(45- )	(57-300)	(2.3-3. )
p value 0	180	7.1	28	1	77	2	2	NA
	(20-600)	(2.7-9. )	(4-52)	(3-27)	(52-295)	(50-293)	(2-3.5)
p value 1		2.6	13	13.	122	133	2	1
		(0.6-7.8)	(2-28)	(1-25)	( 6-300)	7-300)	(1.5-3.3)	(1-3)
	<0.001	<0.001	<0.001;	>0.05	>0.05	>0.05	<0.001	NA
			<0.002
p value 2	15	3.0	13	11.5	1 9	1	2	1.5
	(0-150)	(0.2-6.4)	(1-28)	(1-22)	(75-300)	( )	(1.5-3.2)	(1-3)
	<0.001	<0.001	<0.001	<0.003;	<0.03;	>0.05	<0.001	NA
				<0.02	>0.05
p value 3	5	2.2	8	6	113		2	2
	(0-150)	(0.2-7.4)	(0-22)	(1-19)	(51-300)	( -300)	(1.2- )	(1-2
	<0.001	<0.001	<0.001	<0.001;	>0.05	>0.05	<0.001	NA
				<0.002
p value 4	15	1.90	10	6	124	148	.8	2
	(0-90)	(0.1-5.6)	(0-17)	( )	(79-300)	(64-300)	(1. -2.7)	(1-2
	<0.001	<0.001	<0.001	<0.001;	<0.02;	<0.03;	<0.001	NA
				<	>0.05	>0.05
p value	5	1.9	6		119	153	1.7	2
	( 0)	(0.1-6.2)	(0-18)	(1-14)	(68-300)	(62-300)	(1.3-2.8)	(1-2
	<0.001	<0.001	<0.001	<0.001	<0.04;	<0.05;	<0.001	NA
					>0.05	>0.05
p value	15	2.1	8	7	117	167	1.8	2
	(0-60)	(0-2- )	(1-28)	(1-18)	(69-300)	( -300)	(1.5-2.8)
	<0.001	<0.001	<0.001	<0.001	<0.03;	< ;	<	NA
					>0.05	>0.0

Datas are expressed as the median ( ) of values from ;
data from 15 were not included after week 2 ( );
P values show significance by with week 0 values;
adjusted for multiple statistical comparisons.
IDA = Index of disease activity;
NA = not applicable.
indicates data missing or illegible when filed

TABLE 14

Changes in Laboratory Measures Following Treatment
of Rh Arthritis pa with cA2

			Platelet				RF
Week of		WBC ×	Count ×	ESR	CRP	SAA	Inverse
Trial	liter	10/liter	10/liter	mm/hour	mg/liter	mg/ml	titer

Screen	117	7.9	353		42	ND	ND
	( )	( .9- 5.2)		( )
P value 0	113		341	55	9.5	245	2.5
	( )	(4. -15.7)	(228-710)	(15- 4)	(5-107)	(18-1900)	(160- 0.240)
p value 1	114	8.5	351	26	5	58	ND
	(96-145)	( .6- )	(223- )	(13-100)	(0-50)	(0-330)
	>0.05	>0.05	>0.05	>0.05	<0.001	<0.001;
						<0.00
p value 2	112	8.2	296		5.5	9	ND
	(95-144)	(4.3-12.7)	( )	( )	(0- 0)	( )
	>0.05	>0.05	<0.04;	<0.02;	<0.001;	< 2;
			>0.05	>0.05	<0.003	< 4
p value 3	110	.0	2 9		7	ND	ND
	(89-151)	( -14.4)	( )	( )	(0- )
	>0.05	>0.05	<0.03;	<0.04;	<0.01;
			>0.05	>0.05	<0.002
p value	112	8.2	314	23	10	ND	ND
	( -148)	(4. )	(186-565)	(10-87)	(0-91)
	>0.05	>0.05	>	4;	<0.00 ;
				>0.0	<0.02
p value 6	116	9.1	339	23	8	ND	ND
	(91-159)	( )	( )	(12- )	(0- )
	>0.05	>0.05	>0.05	<0.03;	<0.001
				>0.05
p value 8	114	7.6			6	ND	480
	(94-153)	(4.2-13.5)	(210-591)	(7-73)	(0- )
	>0.05	>0.05	>0.05	>0.05	<0.001		>0.05

Data are expressed as the median (range) of values 20 patients;
data from patient 15 not included after week 2 (dropout).
For (RF), only 0 the particle agglutination assay were included (No. = 14).
P values significance by Mann-Whitney test compared with week 0 values; adjusted for multiple statistical
ND = not done.
Normal ranges: hem (Hgb) 120-160 g/liter (F), 135-175 (M); white blood cell (WBC) 3-11 × 10⁹/liter; platelet 150-400 × 10⁹/liter; erythrocyte sedimentation rate ( ) <15 mm (F), <10 mm/hour (M); C-reactive (CRP) <10 liter; A(SAA) <10 mg/ml.
indicates data missing or illegible when filed

All DMARDs were discontinued at least 1 month prior to trial entry. Patients were allowed to continue on a nonsteroidal anti-inflammatory drug and/or prednisolone (<12.5 mg/day) during the trial. The dosage of these agents was kept stable for 1 month prior to trial entry and during the course of the trial, and no parenteral corticosteroids were allowed during these periods. Simple analgesics were allowed ad libitum. Patients with other serious medical conditions were excluded. Specific exclusions included serum creatinine>150 umol/liter (normal range 60-120 umol/liter), hemoglobin (Hgb)<90 gm/liter (normal range 120-160 gm/liter [females]; 135-175 gm/liter [males]), white blood cell count (WBC)<4.times.10 g/liter (normal range 4-11.times.10.sup.9/liter), platelet count<100.times.10 g/liter (normal range 150-400.times.10.sup.9/liter), and abnormal liver function tests or active pathology on chest X-Ray.
All patients gave their informed consent for the trial, and approval was granted by the local ethics committee.
Treatment
The cA2 antibody was stored at 4.degree. C. in 20 ml vials containing 5 mg of cA2 per milliliter of 0.01 M phosphate buffered saline in 0.15M sodium chloride at a pH of 7.2 and was filtered through a 0.2 .mu.m sterile filter before use. The appropriate amount of cA2 was then diluted to a total volume of 300 ml in sterile saline and administered intravenously via a 0.2 .mu.m in-line filter over a 2 hour period.
Patients were admitted to hospital for 8-24 hours for each treatment, and were mobile except during infusions. The trial was of an open, uncontrolled design, with a comparison of two treatment schedules. Patients 1 to 5 and 11 to 20 received a total of 2 infusions, each of 10 mg/kg cA2, at entry to the study (week 0) and 14 days later (week 2). Patients 6 to 10 received 4 infusions of 5 mg/kg activity included complete blood counts, C-reactive protein (CRP; by rate nephelometry) and the erythrocyte sedimentation rate (ESR; Westergren). Follow-up assessments were made at monthly intervals after the conclusion of the formal trial period, in order to assess the duration of response.
Analysis of improvement in individual patients was made using two separate indices. Firstly, an index of disease activity (IDA) was calculated for each time point according to the method of Mallya and Mace (Mallya et al., Rheumatol. Rehab. 20:14-17 (1981), with input variable of morning stiffness, pain score, Ritchie Index, grip strength, ESR and Hgb. The second index calculated was that of Paulus (Paulus et al., Arthritis Rheum. 33:477-484 (1990) which uses input variables of morning stiffness, ESR, joint pain/tenderness, joint swelling, patient's and physician's global assessment of disease severity. In order to calculate the presence or otherwise of a response according to this index, two approximations were made to accommodate our data. The 28 swollen joint count used by us (nongraded; validated in Fuchs et al., Arthritis Rheum. 32:531-537 (1989)) was used in place of the more extensive graded count used by Paulus, and the patient's and physician's global assessments of response recorded by us were approximated to the global assessments of disease activity used by Paulus infra. In addition to determining response according to these published indices, we selected 6 disease activity assessments of interest (morning stiffness, pain score, Ritchie index, swollen joint count, ESR and CRP) and calculated their mean percentage improvement. We have used FIGS. 24 and 25 to give an indication of the degree of improvement seen in responding patients.
Immunological Investigations
Rheumatoid factors were measured using the rheumatoid arthritis particle agglutination assay (PAPA, FujiBerio Inc., Tokyo, Japan), in which titers of 1/160 or greater were considered significant. Rheumatoid factor isotypes were measured by ELISA (Cambridge Life Sciences, Ely, UK). The addition of cA2 at concentrations of up to 200 .mu.g/ml to these assay cA2, at entry, and days 4, 8 and 12. The total dose received by the 2 patient groups was therefore the same at 20 mg/kg.
Assessment Safety Monitoring
Vital signs were recorded every 15 to 30 minutes during infusions, and at intervals for up to 24 hours post infusion. Patients were questioned concerning possible adverse events before each infusion and at weeks 1, 2, 3, 4, 6, and 8 of the trial. A complete physical examination was performed at screening and week 8. In addition, patients were monitored by standard laboratory tests including complete blood count, C3 and C4 components of complement, IgG, IgM and IgA, serum electrolytes, creatinine, urea, alkaline phosphatase, aspartate transaminase and total bilirubin. Sample times for these tests were between 0800 and 0900 hours (pre-infusion) and 1200-1400 hours (24 hours post completion of the infusion). Blood tests subsequent to day 1 were performed in the morning, usually between 0700 and 1200 hours. Urine analysis and culture were also performed at each assessment point.
Response Assessment
The patients were assessed for response to cA2 at weeks 1, 2, 3, 4, 6 and 8 of the trial. The assessments were all made between 0700 and 1300 hours by the same observer. The following clinical assessments were made: duration of morning stiffness (minutes), pain score (0 to 10 cm on a visual analog scale), Ritchie Articular Index (maximum 69; Ritchie et al., Quart. J. Med. 147:393-406 (1968)), number of swollen joints (28 joint count; validated in Fuchs et al., Arthritis Rheum. 32:531-537 (1989), grip strength (0 to 300 mm Hg, mean of 3 measurements per hand by sphygmomanometer cuff) and an assessment of function (the Stanford Health Assessment Questionnaire (HAQ) modified for British patients; 34). In addition, the patients' global assessments of response were recorded on a 5-point scale (worse, no response, fair response, good response, excellent response). Routine laboratory indicators of disease systems did not alter assay results (data not shown). Antinuclear antibodies were detected by immunofluorescence on HEpo 2 cells (Biodiagnostics, Upton, Worcs. UK) and antibodies to extractable nuclear antigens were measured by counter immunoelectrophoresis with poly-antigen extract (Biodiagnostics). Sera positive by immunofluorescence were also screened for antibodies to DNA by the Farr assay (Kodak Diagnostics, Amersham, UK). Anti-cardiolipin antibodies were measured by ELISA (Shield Diagnostics, Dundee, Scotland). Serum amyloid A (SAA) was measured by sandwich ELISA (Biosource International, Camarillo, Calif., USA). Antiglobulin responses to the infused chimeric antibody were measured by an in-house ELISA, using cA2 as a capture reagent.
Cytokine Assays
Bioactive TNF was measured in sera using the WEHI 164 clone 13 cytotoxicity assay (Espevik et al., J. Imm. Methods 95:99-105 (1986). Total IL-6 was measured in sera using a commercial immunoassay (Medgenix Diagnostics, SA, Belgium) and by a sandwich ELISA developed “in house” using monoclonal antibodies provided by Dr. F. di Padova (Basel, Switzerland). Microtiter plates were coated with monoclonal antibody LNI 314-14 at a concentration of 3 ug/ml for 18 hours at 4.degree. C. and blocked with 3% bovine serum albumin in 0.1M phosphate buffered saline, pH 7.2. Undiluted sera or standards (recombinant hIL 6, 0-8.1 ug/ml) were added to the wells in duplicate and incubated for 18 hours at 4.degree. C. Bound IL-6 was detected by incubation with monoclonal antibody LNI 110-14 for 90 minutes at 37.degree. C., followed by biotin labeled goat anti-murine IgG2b for 90 minutes at 37.degree. C. (Southern Biotechnology, Birmingham, Ala.). The assay was developed using streptavidin-alkaline phosphatase (Southern Biotechnology) and p-nitrophenylphosphate as a substrate and the optical density read at 405 nm.
Statistics
Comparisons between week 0 and subsequent time points were made for each assessment using the Mann-Whitney test. For comparison of rheumatoid factor (RAPA) titers, the data were expressed as dilutions before applying the test.
This was an exploratory study, in which prejudgements about the optimal times for assessment were not possible. Although it has not been common practice to adjust for multiple statistical comparisons in such studies, a conservative statistical approach would require adjustment of p values to take into account analysis at several time points. The p values have therefore been presented in two forms: unadjusted, and after making allowance for analysis at multiple time points by use of the Bonferroni adjustment. Where p values remained <0.001 after adjustment, a single value only is given. A p value of <0.05 is considered significant.

Results

Safety of cA2
The administration of cA2 was exceptionally well tolerated, with no headache, fever, hemodynamic disturbance, allergy or other acute manifestation. No serious adverse events were recorded during the 8-week trial. Two minor infective episodes were recorded, patient 15 presented at week 2 with clinical features of bronchitis and growth of normal commensals only on sputum culture. She had a history of smoking and of a similar illness 3 years previously. The illness responded promptly to treatment with amoxicillin, but her second cA2 infusion was withheld and the data for this patient are therefore not analyzed beyond week 2. Patient 18 showed significant bacteriuria on routine culture at week 6 (>10.sup.5/ml; lactose fermenting coliform), but was asymptomatic. This condition also responded promptly to amoxicillin.
Routine analysis of blood samples showed no consistent adverse changes in hematological parameters, renal function, liver function, levels of C3 or C4 or immunoglobulins during the 8 weeks of the trial. Four minor, isolated and potentially adverse laboratory disturbances were recorded. Patient 2 experienced a transient rise in blood urea, from 5.7 mmol/liter to 9.2 mmol/liter (normal range 2.5 to 7 mmol/liter), with no change in serum creatinine. This change was associated with the temporary use of a diuretic, prescribed for a non-rheumatological disorder. The abnormality normalized within 1 week and was classified as “probably not” related to cA2. Patient 6 experienced a transient fall in the peripheral blood lymphocyte count, from 1.6 to 0.8.times.10.sup.9/liter (normal range 1.0-4.8.times.10.sup.9/liter). This abnormality normalized by the next sample point (2 weeks later), was not associated with any clinical manifestations and was classified as “possible related” to cA2. Patients 10 and 18 developed elevated titers of anti-DNA antibodies at weeks 6 and 8 of the trial, with elevated anti-cardiolipin antibodies being detected in patient 10 only. Both patients had a pre-existing positive antinuclear antibody and patient 10 had a history of borderline lymphocytopenia and high serum IgM. There were no clinical features of systemic lupus erythematosus and the laboratory changes were judged ‘possibly related’ to cA2.
Efficacy of cA2 Disease Activity
The pattern of response for each of the clinical assessments of disease activity and the derived IDA are shown in Table 13. All clinical assessments showed improvement following treatment with cA2, with maximal responses from week 3. Morning stiffness fell from a median of 180 minutes at entry to 5 minutes at week 6 (p<0.001, adjusted), representing an improvement of 73%. Similarly, the Ritchie Index improved from 28 to 6 at week 6, (p<0.001, adjusted, 79% improvement) and the swollen joint count fell from 18 to 5, (p<0.001, adjusted, 72% improvement). The individual swollen joint counts for all time points are shown in FIG. 24. Grip strength also improved; the median grip strength rose from 77 (left) and 92 (right) mm Hg at entry to 119 (left) and 153 (right) mmHg at week 6 (p<0.04, p<0.05, left and right respectively; p>0.05 after adjustment for multiple comparisons). The IDA showed a fall from a median of 3 at entry to 1.7 at week 6 (p<0.001, adjusted). Patients were asked to grade their responses to cA2 on a 5 point scale. No patient recorded a response of “worse” or “no change” at any point in the trial. “Fair”, “good” and “excellent” responses were classed as improvements of 1, 2 and 3 grades respectively. At week 6, the study group showed a median of 2 grades of improvement (Table 13).
We also measured changes in the patients' functional capacity, using the HAQ modified for British patients (range 0-3). The median (range) HAQ score improved from 2 (0.9-3) at entry to 1.1 (0-2.6) by week 6, (p<0.001; p<0.002 adjusted).
The changes in the laboratory tests which reflect disease activity are shown in Table 14. The most rapid and impressive changes were seen in serum CRP, which fell from a median of 39.5 mg/liter at entry to 8 mg/liter by week 6 of the trial (p<0.001, adjusted; normal range <10 mg/liter), representing an improvement of 80%. Of the 19 patients with elevated CRP at entry, 17 showed falls to the normal range at some point during the trial. The improvement in CRP was maintained in most patients for the assessment period (Table 14 and FIG. 25); the exceptions with high values at 4 and 6 weeks tended to be those with the highest starting values (data not shown). The ESR also showed improvement, with a fall from 55 mm/hour at entry to 23 mm/hour at week 6 (p<0.03; p>0.05 adjusted; 58% improvement; normal range <10 mm/hour, <15 mm/hour, males and females respectively). SAA levels were elevated in all patients at trial entry, and fell from a median of 245 mg/ml to 58 mg/ml at week 1 (p<0.003, adjusted; 76% improvement; normal range <10 mg/ml) and to 80 mg/ml at week 2 (p<0.04, adjusted). No significant changes were seen in Hgb, WBC or platelet count at week 6, although the latter did improve at weeks 2 and 3 compared with trial entry (Table 14).
The response data have also been analyzed for each individual patient. The majority of patients had their best overall responses at week 6, at which time 13 assessed their responses as “good” while 6 assessed their responses as “fair”. Eighteen of the 19 patients who completed the treatment schedule achieved an improvement in the index of Disease Activity (Mallya et al., Rheumatol. Rehab. 20:14-17 (1981) of 0.5 or greater at week 6, and 10 achieved an improvement of 1.0 or greater. All patients achieved a response at week 6 according to the index of Paulus (Paulus et al., Arthritis Rheum. 33:477-484 (1990). Finally, all patients showed a mean improvement at week 6 in the 6 selected measures of disease activity (as presented above) of 30% or greater, with 18 of the 19 patients showing a mean improvement of 50% or greater.
Although the study was primarily designed to assess the short-term effects of cA2 treatment, follow-up clinical and laboratory data are available for those patients followed for sufficient time (number=12). The duration of response in these patients, defined as the duration of a 30% (or greater) mean improvement in the 6 selected disease activity measures, was variable, ranging from 8 to 25 (median 14) weeks.
Comparison of the clinical and laboratory data for patients treated with 2 infusions of cA2 (each at 10 m/kg) compared with those treated with 4 infusions (each at 5 mg/kg) showed no significant differences in the rapidity or extent of response (data not shown).
Immunological Investigations and Cytokines
Measurement of rheumatoid factor by RAPA showed 14 patients with significant titers (> 1/160) at trial entry. Of these, 6 patients showed a fall of at least 2 titers on treatment with cA2, while the remaining patients showed a change of 1 titer or less. No patient showed a significant increase in RF titer during the trial. The median RF titer in the 11 patients fell from ½, 560 at entry to 1/480 by week 8 (p>0.05; Table 14). Specific RF isotypes were measured by ELISA, and showed falls in the 6 patients whose RAPA had declined significantly, as well as in some other patients. Median values for the three RF isotypes in the 14 patients seropositive at trial entry were 119, 102 and 62 IU/ml (IgM, IgG and IgA isotypes respectively) and at week 8 were 81, 64 and 46 IU/ml (p>0.05).
We tested sera from the first 9 patients for the presence of bioactive TNF, using the WEHI 164 clone 13 cytotoxicity assay (Espevik et al., J. Imm. Methods 95:99-105 (1986). In 8 patients, serum sets spanning the entire trial period were tested, while for patient 9, one pre-trial, one period were tested, patient, one pre, one intermediate and the last available sample only were tested. The levels of bioactive TNF were below the limit of sensitivity of the assay in the presence of human serum (1 pg/ml). Since production of CRP and SAA are thought to be regulated in large part by IL-6, we also measured serum levels of this cytokine, using 2 different assays which measure total IL-6. In the Medgenix assay, IL-6 was significantly elevated in 17 of the 20 patients at entry. In this group, levels fell from 60 (18-500) pg/ml to 40 (0-230) pg/ml at week 1 (p>0.05; normal range <10 pg/ml) and to 32 (0-210) pg/ml at week 2 (p<0.005, p<0.01, adjusted). These results were supported by measurement of serum IL-6 in the first 16 patients in a separate ELISA developed in-house. IL-6 was detectable in 11 of the 16, with median (range) levels falling from 210 (25-900) pg/ml at entry to 32 (01, 700) pg/ml at week 1 (p<0.02, p<0.04, adjusted; normal range <10 pg/ml) and to 44 (0-240) pg/ml at week 2 (p<0.02, p<0.03, adjusted).
We tested sera from the first 10 patients for the presence of anti-globulin responses to the infused chimeric antibody, but none were detected. In many patients however, cA2 was still detectable in serum samples taken at week 8 and this can have interfered with the ELISA.
Discussion
This is the first report describing the use of anti-TNF.alpha. antibodies in human autoimmune disease. Many cytokines are produced in rheumatoid synovium, but we chose to target specifically TNF.alpha. because of mounting evidence that it was a major molecular regulator in RA. The study results presented here support that view and allow three important conclusions to be drawn.
First, treatment with cA2 was safe and the infusion procedure was well tolerated. Although fever, headache, chills and hemodynamic disturbance have all been reported following treatment with anti CD4 or anti CDw52 in RA, such features were absent in our patients. Also notable was the absence of any allergic event despite repeated treatment with the chimeric antibody, although the interval between initial and repeat infusions can have been too short to allow maximal expression of any anti-globulin response. The continuing presence of circulating cA2 at the conclusion of the trial may have precluded detection of antiglobulin responses, but also implied that any such responses were likely to be of low titre and/or affinity. Although we recorded 2 infective episodes amongst the study group, these were minor and the clinical courses were unremarkable. TNF.alpha. has been implicated in the control of listeria and other infections in mice (Havell et al., J. Immunol. 143:2894-2899 (1989), but our limited experience does not suggest an increased risk of infections after TNF.alpha. blockade in man.
The second conclusion concerns the clinical efficacy of cA2. The patients we treated had long-standing, erosive, and for the most part seropositive disease, and had each failed therapy with several standard DMARDs. Despite this, the major clinical assessments of disease activity and outcome (morning stiffness, pain score, Ritchie index, swollen joint count and
HAQ score) showed statistically significant improvement, even after adjustment for multiple comparisons. All patients graded their response as at least “fair”, with the majority grading it as “good”. In addition, all achieved a response according to the criteria of Paulus and showed a mean improvement of at least 30% in 6 selected disease activity measures.
The improvements in clinical assessments following treatment with cA2 appear to be at least as good as those reported following treatment of similar patients with antileukocyte antibodies. The two therapeutic approaches can already be distinguished, however, by their effects on the acute phase response, since in several studies of antileukocyte antibodies, no consistent improvements in CRP or ESR were seen. In contrast, treatment with cA2 resulted in significant falls in serum CRP and SAA, with normalization of values in many patients. The changes were rapid and marked, and in the case of CRP, sustained for the duration of the study (Table 14). The falls in ESR were less marked, achieving statistical significance only when unadjusted (Table 14).
These results are consistent with current concepts that implicate TNF.alpha. in the regulation of hepatic acute phase protein synthesis, either directly, or by control of other, secondary, cytokines such as IL-6 (Fong et al., J. Exp. Med. 170:1627-1633 (1989); Guerne et al., J. Clin. Invest. 83:585-592 (1989)). In order to investigate the mechanism of control of the acute phase response in our patients, we measured serum TNF.alpha. and IL-6 before and after cA2 treatment. Bioactive TNF.alpha. was not detectable in baseline or subsequent sera. We used 2 different assays for IL-6, in view of previous reports of variability between different immunoassays in the measurement of cytokines in biological fluids (Roux-Lombard et al., Clin. Exp. Rheum. 10:515-520 (1992), and both demonstrated significant falls in serum IL-6 by week 2. These findings support the other objective laboratory changes induced by cA2, and provide in vivo evidence that TNF.alpha. is a regulatory cytokine for IL-6 in this disease. Amongst the other laboratory tests performed, rheumatoid factors fell significantly in 6 patients.
Neutralization of TNF.alpha. can have a number of beneficial consequences, including a reduction in the local release of cytokines such as IL-6 and other inflammatory mediators and modulation of synovial endothelial/leukocyte interactions. cA2 can also bind directly to synovial inflammatory cells expressing membrane TNF.alpha., with subsequent in situ cell lysis.
The results obtained in this small series have important implications, both scientifically and clinically. At the scientific level, the ability of the neutralizing antibody, cA2, to reduce acute phase protein synthesis, reduce the production of other cytokines such as IL-6, and significantly improve the clinical state demonstrates that it is possible to interfere with the cytokine network in a useful manner without untoward effects. Due to the many functions and overlapping effects of cytokines such as IL-1 and TNF.alpha., and the fact that cytokines induce the production of other cytokines and of themselves, there had been some pessimism as to whether targeting a single cytokine in vivo would have any beneficial effect (Kingsley et al., Immunol. Today 12:177-179 (1991), Trentham, Curr. Opin. Rheumatol. 3:369-372 (1991)). This view is clearly refuted. On the clinical side, the results of short-term treatment with cA2 are significant and confirm that TNF.alpha. is useful as a new therapeutic target in RA.

Example XXIV

Treatment of Rheumatoid Arthritis in Humans with cA2 Antibody Patients

Patients were recruited from the clinics of four cooperating trial centers or after referral from outside physicians. Patients aged 18-75 were included if they met the criteria of the American College of Rheumatology for the diagnosis of rheumatoid arthritis, had disease for at least six months, had a history of failed treatment with at least one disease modifying anti-rheumatic drug (DMARD) and had evidence of erosive disease on radiography of hands and feet. In addition, patients had to have active disease, as defined by the presence of six or more swollen joints plus at least three of four secondary criteria (duration of morning stiffness .gtoreq.45 minutes; .gtoreq.6 tender or painful joints; erythrocyte sedimentation rate (ESR) .gtoreq.28 mm/h; C-reactive protein (CRF) .gtoreq.20 mg/L). Patients with severe physical incapacity (Steinbrocker class IV) or with clinically evident joint ankylosis were excluded. Other exclusion criteria included: severe anemia (haemoglobin<8.5 g/dL); leucopenia (white cells<3.5.times.10.sup.9/L, neutrophils<1.5.times.10.sup.9/L) or thrombocytopenia (100.times.10.sup.9/L); elevation of liver function tests to over three times the upper limit of normal or of serum creatine to over 150 .mu.mol/L; or active pathology on chest film. Patients were also excluded if they had a history of previous administration of murine monoclonal antibodies, a history of cancer or HIV infection, or current other serious medical conditions. Female patients of child-bearing age had to be using an effective method of birth control and to have a negative pregnancy test before entry.
No patient had received other experimental drugs targeted to TNF (e.g., oxpentifylline) in the previous three months. Patients taking disease-modifying anti-rheumatic drugs at screening were withdrawn from their therapy at least four weeks before entry. Patients taking low-dose oral corticosteroids (prednisolone .ltoreq.12.5 mg per day) or non-steroidal anti-inflammatory drugs at screening were allowed to continue on stable doses. Additional steroids by injection or other routes were not allowed. Simple analgesics were freely allowed.
All patients gave their informed consent for the trial, which was approved by each of the local regional ethics committees.
Study Infusions
The cA2 antibody was supplied as a sterile solution containing 5 mg cA2 per ml of 0.01 mol/L phosphate-buffered saline in 0.15 mol/L sodium chloride with 0.01% polysorbate 80, pH 7.2. The placebo vials contained 0.1% human serum albumin in the same buffer. Before use, the appropriate amount of cA2 or placebo was diluted to 300 mL in sterile saline by the pharmacist, and administered intravenously via a 0.2 .mu.m in-line filter over 2 hours. The characteristics of the placebo and cA2 infusion bags were identical, and the investigators and patients did not know which infusion was being administered.
Assessments
Patients were seen at an initial screening visit and if eligible, were entered within four weeks. On the day of entry, patients were admitted to the hospital and randomized (in blocks of 6, stratified for center) to one of three groups (24 per group). The first group received a single infusion of placebo. The other two groups received one infusion of cA2, 1 mg/kg (“low dose”) and 10 mg/kg (“high dose”). The doses of cA2 were chosen on the basis of experience in the open-label trial and by extrapolation from the anti-TNF-treated collagen-arthritis mice.
Patients were monitored for adverse events during infusions and regularly thereafter, by interviews, physical examination, and laboratory testing.
Before the start of the trial, all clinical observers agreed on a standard technique to assess joints, and to establish protocols for the collection of other clinical data. In each center, patients were assessed by the same clinical observer at each evaluation visit, usually between 0800 and 1100 hour. Clinical observers were additionally blinded to the results of laboratory testing for acute-phase measures (ESR and CRP).
The six primary disease-activity assessments were chosen to allow analysis of the response in individual patients according to the Paulus index. The assessments contributing to this index were the tender and swollen joint scores (60 and 58 joints, respectively, hips not assessed for swelling; graded 0-3), the duration of morning stiffness (minutes), the patient's and observer's assessment of disease severity (on a point scale, ranging from 1 (symptom-free) to 5 (very severe) and ESR. Patients were considered to have responded if at least four of the six variables improved, defined as at least 20% improvement in the continuous variables, and at least two grades of improvement or improvement from grade 1 to 1 in the two disease-severity assessments (Paulus 20% response). Improvements of at least 50% in the continuous variables were also used (Paulus 50%).
Other disease-activity assessments included the pain score (0-10 cm on a visual analogue scale (VAS)), an assessment of fatigue (0-10 cm VAS), and grip strength (0-300 mm Hg, mean of three measurements per hand by sphygmomanometer cuff).
The ESR was measured at each study site with a standard method (Westergen). CRP (Abbott fluorescent polarizing immunoassay) and rheumatoid factor (rheumatoid-arthritis particle-agglutination assay (RAPA, FujiBerio, Tokyo); titres.gtoreq.160 were taken to be important) were measured in stored frozen serum samples shipped to a central laboratory.
Statistics
The analysis was on the basis of intention to treat. The sample size was chosen as having an 80% probability of achieving a statistically significant (p<0.05) result if the true response rates were 10% and 40% in the placebo and 10 mg/kg cA2 groups, respectively. Fisher's exact test was used to compare the groups for baseline sex ratio and rheumatoid factor status and for Paulus response rates. Comparisons between groups for other demographic features and for individual disease activity assessments were by analysis of variance, or Cochran-Mantel-Haenszel statistics where appropriate (baseline comparison of disease-modifying anti-rheumatic drugs usage, patient's and observer's assessments of disease severity/activity). The Paulus 20% response rate at week 4 was defined as the primary efficacy endpoint, with other time points and variables considered supportive. Levels of significance were therefore not adjusted for multiple comparisons.
Results
Seventy-two patients were initially randomized. One patient presented two weeks after treatment with 1 mg/kg cA2 with probable pneumonia that required admission to the hospital. The patient was withdrawn and, according to protocol, another patient was recruited. Thus, the intention-to-treat analysis brought the number analyzed in the 1 mg/kg group to 25 patients and the total number to 73.
The three groups were well-matched at entry, with no significant differences in age, sex ratio, disease duration, number of failed disease-modifying anti-rheumatic drugs, or percentage of patients with significant titre of rheumatoid factor (Table 15). Demographic data were similar between the four sites. The patients had active disease at entry, as judged by the presence of multiple tender and swollen joints, high pain scores, substantial morning stiffness, raised acute-phase measures (Table 16). Comparison between groups revealed no significant differences for any of the clinical and laboratory indices of disease activity at entry.
The response rates at Paulus 20% and 50% are shown in Table 17. Only 2 of 24 placebo recipients achieved a 20% response at week 4. By contrast, 19 of 24 patients treated with 10 mg/kg cA2 achieved a response by week 4 (p0.0001 compared with placebo). The response rates in the 1 mg/kg group were intermediate, with 11 of 25 patients responding at week 4 (p=0.0083). Analysis of the Paulus 50% response showed similar differences between the groups, with 14 of 24 high-dose cA2 patients responding (p=0.0005), compared with 2 of 24 patients in the placebo group. Analysis of the response data for corticosteroid use showed that patients who were taking steroids behaved no differently in their responses from non-steroid-treated patients.
Although secondary to the differences in overall response rates, analysis of changes in individual disease-activity assessments was also of interest (Table 16). Significant improvements were seen in both cA2 groups for each of the clinical assessments. For many assessments, maximum mean improvements in cA2-treated groups exceeded 60%. Among the laboratory measures, significant falls were seen in both cA2 groups for ESR, CRP, and platelet counts, with the best improvements seen in the high-dose group. The changes in CRP were particularly rapid in onset and impressive in extent, with many individual patients achieving normal concentrations (10 mg/L, data not shown). In addition, significant improvements relative to placebo were seen for haemoglobin, especially in the high-dose cA2 group. Trends towards a fall in white cell count (from increased counts at entry) in both cA2 groups supported the changes in other laboratory measures, but did not reach statistical significance (Table 16).
Detailed time response profiles for six disease-activity assessments common to the American College of Rheumatology and the European League Against Rheumatism core-sets showed rapid and highly significant falls in the cA2-treated groups compared with placebo, with significant inter-group differences evident as early as 24 and 72 h (CRP and all other assessments, respectively).
Seeking possible dose-response relations, we compared response rates between the cA2 groups. We found no difference in 20% or 50% Paulus responses at week 2, but significantly higher response rates for the high-dose group at week 4 (likelihood ratio 1.8, 95% CI 1.1, 2.9, p=0.0186; 2.1, 1.1, 4.1, p=0.0450, for Paulus 20% and 50%, respectively). A similar analysis for each of the individual disease-activity assessments showed no greater benefit with the higher dose at week 2 of the study, except for haemoglobin (least squares mean difference 0.5, 95% CI 0.1, 0.9, p=0.021). By week 4, however, some diminution of the response in the 1 mg/kg group was evident for several assessments; responses in the 120 mg/kg group were maintained (Table 16). As a result, significantly better responses were seen at this time in the high-dose group, including pain score (least-squares mean difference −1.8, 95% CI −3.4 −0.2, p=0.036), right (28.4, 5.4, 51.3, p=0.018) and left grip strength (20.6, 3.3, 37.9, p=0.022), observer's assessment of disease severity (−0.8, −1.3, −0.4, p<0.035), ESR (−15.0, −23.6 to −1.4 p=0.035), CRP (−20.7, −32.1, −9.2, p<0.001), and haemoglobin (0.5, 0.0, 1.0, p=0.042).
The infusions of cA2 and placebo were well tolerated, with no episodes of fever or hemodynamic disturbance. The adverse events recorded during the 4 weeks after treatment are shown in Table 18. In all, two-thirds of the adverse events occurred in the cA2 groups. Infections formed the largest group, with 5 infections recorded in the 1 mg/kg group and 1 each in those receiving 10 mg/kg cA2 and placebo. Of the 72 initially randomized, 2 patients had severe adverse events. One was the patient with probable pneumonia. The patient recovered fully with treatment, but was withdrawn and replaced. This event was judged “possibly” related to cA2. A second patient presented 1 week after treatment with 10 mg/kg cA2 with a pathological fracture of the clavicle, but continued in the study. In retrospect, a minor bony abnormality was evident on an X-ray film taken pretreatment, and the event was judged “probably not” related to cA2.

TABLE 15

Demographic Features

Group

Placebo

1 mg/kg cA2	10 mg/kg
(n = 24)	(n = 25)	cA2 (n = 24)

	Age (yr)	48-2 (11-9)	56-2 (12-2)	50-6 (13-1)
	M/F	7/17	5/25	4/20
	Disease	9-0 (7-3)	7-5 (4-8)	7-3 (5-2)
	Duration
	Previous	3-7 (1-9)	(3-5)	3-1 (1-7)
	Drugs*
	Pneumonia		96%	35%
	Factor
	(seropositive)

Mean (SC).
*Number of disease-modifying anti-theomatic drugs previously used.
indicates data missing or illegible when filed

TABLE 16

D Activity Ass

Statistical analysis vs. Placebo

Summary

1

10 mg/kg cA2

A Wk	acebo	1 mg/kg cA2	10 mg/kg cA2	Le	95% CI	p	Le	95% CI	p

Tender joint

0	27.8 (13.5)	29.1 (14.1)	28.1 (12.7)
2	25.7 (16.6)	12.1 (10.2)	11.1 (6.9)	−14.8	−21.2, −8.4	<0.001	−14.8	−20.2, −9.5	<0.001
4	26.2 (15.5)	16.9 (12.1)	11.3 (9.8)	−10.9	−6.4, −5.3	<0.001	−15.2	−21.2, −9.2	<0.001
Swollen
(0-58)
0	23.4 (10.5)	21.4 (10.6)	21.8 (11.5)
2	24.2 (12.1)	11.1 (8.1)	8.2 (5.5)	−10.9	−15.6, −6.3	<0.001	−14.4	−19.6, −9.2	<0.001
4	23.0 (11.2)	12.9 (8.8)	8.6 (6.4)	−8.2	−12.8, −3.6	0.001	−12.7	−17.8, −7.5	<0.001
Pain Score
(0-10 cm)
0	6.8 (2.8)	6.6 (2.6)	6.7 (2.5)
2	6.9 (2.6)	2.5 (2.6)	2.6 (2.1)	−1.3	−5.7, −2.9	<0.001	−4.3	−5.8, −2.8	<0.001
4	6.9 (2.5)	4.2 (2.9)	2.5 (1.8)	−2.6	−4.2, −0.9	0.003	−4.3	−5.8, −2.9	<0.001
Morning
Stiffness
(min)
0	132.3 (286.7)	142.0 (122.0)	143.1 (105.5)
2	150.6 (284.0)	27.4 (48.7)	10.3 (14.9)	−88.9	−147.5, −30.3	0.004	−101.2	−156.4, −16.1	<0.001
4	172.3 (300.1)	99.6 (286.3)	8.3 (13.6)	−33.4	−156.4, 89.6	0.592	−124.8	−188.9, −60.8	<0.001
Fatigue S
(0-10 cm)
0	6.3 (2.3)	6.5 (2.6)	5.6 (2.4)
2	5.8 (2.9)	3.2 (2.7)	2.8 (2.3)	−2.6	−4.3, −1.0	−0.003	−2.3	−3.9, −0.7	0.006
4	5.6 (3.0)	3.8 (2.8)	2.3 (1.7)	−1.9	−3.6, −0.2	0.028	−2.6	4.3, −1.0	0.003
Grip Strength,
(0-300
mm Hg)
0	120.7 (50.2)	102.4 (48.8)	117.0 (64.1)
2	122.7 (51.5)	161.8 (78.3)	175.3 (79.1)	55.8	32.6, 79.0	<0.001	56.4	35.0, 77.3	<0.001
4	119.1 (50.2)	131.8 (65.0)	175.2 (78.6)	31.3	15.6, 46.9	<0.001	59.9	35.9, 83.9	<0.001
Grip Strength,
left (0-300
mm Hg)
0	120.0 (58.4)	100.8 (46.8)	108.4 (50.5)
2	123.3 (64.9	152.4 (72.0)	157.2 (65.1)	46.7	23.7, 69.6	<0.001	45.4	28.9, 52.0	<0.001
4	120.9 (58.4)	126.6 (65.8)	155.1 (60.9)	25.0	6.5, 43.5	0.010	45.8	28.9, 62.7	<0.001
Disease
Severity,

(1-5)
0	3.8 (0.5)	3.7 (0.5)	3.6 (0.6)
2	3.8 (0.8)	3.5 (0.7)	2.6 (1.0)	−1.2	−1.6, −0.8	<0.001	−1.1	−1.6 −0.6	<0.001
4	3.3 (0.8)	3.0 (0.8)	2.6 (0.8)	−0.7	−1.2, −0.3	0.002	−1.2	−1.7 −0.8	<0.001
Disease
Severity,
Observer
0	3.7 (0.7)	3.7 (0.5)	3.6 (0.7)
2	3.5 (0.8)	2.5 (0.8)	2.3 (0.6)	−1.0	−1.5, −0.6	<0.001	−1.2	−1.6, −0.8	<0.001
4	3.6 (2.0)	3.0 (1.0)	2.2 (0.6)	−0.6	−1.1, −0.1	0.036	−1.4	−1.9, −1.0	<0.001
SR ( )
0	63.1 (24.8)	58.1 (25.5)	63.1 (27.6)
2	67.0 (27.4)	41.8 (24.6)	42.4 (25.2)	−23.1	−35.9, −10.4	<0.001	−24.9	−39.0, −10.9	<0.001
4	65.1 (29.8)	52.4 (32.3)	42.7 (24.6)	−10.7	−26.4, 5.1	0.185	−22.5	−38.7, −6.3	0.009
CRP (mg/L)
0	64 (42)	67 (41)	64 (36)
2	53 (30)	39 (39)	28 (29)	−19.1	−34.1, −4.1	0.016	−24.3	−38.8, −9.8	0.002
4	60 (42)	58 (39)	35 (29)	−7.7	−20.5, 5.1	0.239	−28.8	−33.7, −12.9	<0.001
H
g/dL
0	11.6 (1.6)	11.8 (1.3)	11.0 (1.1)
2	10.9 (1.5)	11.5 (1.2)	11.2 (1.1)	0.4	0.0, 0.7	0.052	0.8	0.5, 1.2	<0.001
4	10.9 (1.7)	11.7 (1.2)	11.4 (1.2)	0.6	0.1, 1.0	0.022	1.1	0.6, 1.5	0.001
WBC (×10 /L)
0	10.7 (3.5)	10.1 (3.5)	9.0 (2.1)
2	10.5 (2.9)	9.2 (3.2)	8.4 (2.5)	−0.	−1.9, 0.4	0.202	−0.4	−1.4, 0.6	0.414
4	10.3 (3.2)	9.3 (4.3)	7.7 (2.0)	−0.4	−1.6, 0.	0.500	−0.9	−1.9, 0.2	0.096
P
(×10 )
0	447 (126)	421 (132)	400 (127)
2	471 (1	375 (111)	368 (117)	−6	−1 , −30	0.001	−56	−89, −22	0.002
4	462 (115)	40 (131)	345 (120)	−29	−073, 16	0.208	−69	−103, −36	0.001

Mean (SD)
*0.2 1 = ba and after and 4 weeks of .
L . = difference.
WBC = white blood cells.
Normal values: ESR, female < , male <10; CRP <10; haemoglobin, female 12-16, male 13.5-17. ; WBC -11, 150-400.
indicates data missing or illegible when filed

TABLE 17

Responses According to Paulus 20% and 50% Criteria at Each Evaluation Point

Data Summary

Statistical Analysis vs. Placebo

Placebo

1 mg/kg cA2

10 mg/kg cA2

1 mg/kg cA2

10 mg/kg cA2

	n = 24	n = 25	n = 24	LR	95% CI	p	LR	95% CI	p

Paulus


20%
Day
3	2 ( )	8 (32%)	7 ( %)		1.1, 14.0	0.0738	3.	0.9, 13.	0.13 5
Week 1	2 ( )	13 (52%)	16 (67%)	6.	2.1, 1 .6	0.00		.0, 21.5	0.0001
Week 2	3 (13%)	15 (60%)	18 (75%)	5.0	2.1, 12.2	0.000	6.0	2.7, 1 .5	<0.0001
Week 3	4 (17%)	12 (48%)	21 (88%)	2.	1.2, 7.1	0.0322	5.3	2.7, 10.	<0.0001
Week 4	2 (8%)	11 (44%)	19 (7 %)	5.3	1.7, 16.9	0.00	9.5	, 23.	<0.0001
P s
0%
Day
3	1 ( %)	6 (24%)	2 ( %)	5.	1.0, 33.1	0.	2.0	0.2,	1.000
Week 1	1 (4)	11 (44%)	12 (50%)	10.6	2.5, 44.6	0.0019	12.0	3.0, 47.5	0.00
Week 2	0	11 (44%)	12 ( %)	NA	NA	0.0002	NA	NA	<0.0001
Week 3	2 ( %)	7 (28%)	13 (54%)	3.	0.9, 13.0	0.1	6.5	2.2, 19.2	0.0013
Week 4	2 ( %)	7 (28%)	14 (58%)	3.	0.9, 13.0	0.1383	.0	2.5,	0.0005

LR = likelihood ratio,
NA = applicable (ratio be calculated no placebo recipients respon at that time).
indicates data missing or illegible when filed

TABLE 18

All Adverse Events Recorded During 4 Weeks After Entry

			1 mg/kg	50 mg/kg
System	Event	Placebo	cA2	cA2

	URTI	1 (0)	2 (0)	1 (1)
	Probable	—	1 (1)	—
	Pleu	—	1 (0)	—
	N	2 (0)	—	—
	Di	1 (1)	—	—
	Abdominal Pain	—	2 (0)	—
	P	—	1 (0)	—
	Blood loss per	—	1 (0)	—
Cardiovascular	Hypertension	1 (0)	1 (1)	1 (1)
	peripheral	—	1 (0)	1 (0)
Skin	H	3 (1)	1 (0)	—
	Infection	—	2 (2)	—
	Injection skin reactivity	—	1 (1)	—
Neurological	D	3 (1)	—	—
	Headache	—	—	1 (0)
M	R	—	1 (0)	—
	P	—	1 (0)	—
	Fracture	—	—	1 (0)
Other	Ma	—	1 (0)	—
	Ri	—	1 (1)	—
		—	1 (0)	—
	S	—	1 (0)	—
	Vas	1 (0)	—	—

URTI—upper r infection. Those events judged by to be
indicates data missing or illegible when filed

Equivalents

Those skilled in the art will know, or be able to ascertain, using no more than routine experimentation, many equivalents to the specific embodiments of the invention described herein. These and all other equivalents are intended to be encompassed by the following claims.

Claims

1-38. (canceled)

39. A method of treating rheumatoid arthritis in a human comprising administering to the human an effective tumor necrosis factor-α inhibiting amount of antibody cA2.

40. A method of treating rheumatoid arthritis in a human comprising administering to the human an effective tumor necrosis factor-α inhibiting amount of a tumor necrosis factor-α antibody, or antigen binding fragment thereof, wherein the antibody binds to human tumor necrosis factor-α.

41. The method of claim 40, wherein the antibody is cA2.

42. A method of treating rheumatoid arthritis in a human comprising administering to the human an effective TNFα-inhibiting amount of an anti-TNFα antibody or antigen-binding fragment thereof, said antibody comprising a human constant region, wherein said antibody or antigen-binding fragment (i) competitively inhibits binding of A2 (ATCC Accession No. PTA-7045) to human tumor necrosis factor TNFα, and (ii) binds to human TNFα with an affinity of at least 1×10⁸liter/mole, measured as an association constant.

43. A method of treating rheumatoid arthritis in a human comprising administering to the human an effective TNFα-inhibiting amount of an anti-TNFα antibody or antigen-binding fragment thereof, said antibody comprising a human IgG1 constant region, wherein said antibody or antigen-binding fragment (i) competitively inhibits binding of A2 (ATCC Accession No. PTA-7045) to human TNFα, and (ii) binds to human TNFα with an affinity of at least 1×10⁸liter/mole, measured as an association constant (Ka).

44. A method of treating rheumatoid arthritis in a human comprising administering to the human an effective TNFα-inhibiting amount of an anti-TNFα antibody or antigen-binding fragment thereof, said antibody comprising a human constant region, wherein said antibody or antigen-binding fragment (i) comprises the antigen-binding regions of A2 (ATCC Accession No. PTA-7045) and (ii) binds to human TNFα with an affinity of at least 1×10⁸liter/mole, measured as an association constant (Ka).

45. A method of treating rheumatoid arthritis in a human comprising administering to the human an effective TNFα-inhibiting amount of an anti-TNFα antibody or antigen-binding fragment thereof; said antibody comprising a human IgG1 constant region, wherein said antibody or antigen-binding fragment (i) comprises the antigen-binding regions of A2 (ATCC Accession No. PTA-7045), and (ii) binds to human TNFα with an affinity of at least 1×10⁸liter/mole, measured as an association constant (Ka).