# Patent

## Title
Methods of treatment with DLL4 antagonists and an anti-hypertensive agent

## Abstract

Methods for treating cancer comprising administering a DLL4 antagonist and one or more anti-hypertensive agents are described. Also described are pharmaceutical compositions comprising a DLL4 antagonist and one or more anti-hypertensive agents, and kits comprising the same.

## Background
CROSS REFERENCE TO RELATED APPLICATIONS
The present application is a U.S. National Phase of International Application No. PCT/US2010/053064, filed Oct. 18, 2010, which claims the benefit of U.S. Provisional Application No. 61/252,473, filed Oct. 16, 2009, each of which are incorporated herein by reference in their entirety.
DESCRIPTION OF THE INVENTION
1. Field of Invention
The present invention relates to the field of oncology and provides novel compositions and methods for treating cancer. The present invention provides a pharmaceutical composition comprising a DLL4 antagonist and one or more anti-hypertensive agents, and methods and kits for using the same.
2. Background
Cancer is one of the leading causes of death in the developed world, with over one million people diagnosed with cancer and 500,000 deaths per year in the United States alone. Overall it is estimated that more than 1 in 3 people will develop some form of cancer during their lifetime. There are more than 200 different types of cancer, four of which—breast, lung, colorectal, and prostate—account for over half of all new cases (Jemal et al., 2003, Cancer J. Clin. 53:5-26).
Increasingly, treatment of cancer has moved from the use of systemically acting cytotoxic drugs to include more targeted therapies that hone in on the mechanisms that allow unregulated cell growth and survival. Tumor angiogenesis, the process by which a tumor establishes an independent blood supply, is a critical step for tumor growth. Efforts to target tumor angiogenesis have emerged as an important strategy for the development of novel cancer therapeutics.
Tumors cannot continue to grow beyond about 2 mm in diameter without developing blood vessels to deliver oxygen and nutrients, and to remove cellular waste. Tumors release angiogenic factors that act on the receptors of endothelial cells of nearby blood vessels, causing proliferation and the development of new blood vessels directed toward the site of angiogenic factor release, i.e., the tumor. This tumor-induced vasculature has received enormous interest as a target for antineoplastic therapy because a relatively small number of blood vessels are critical for the survival and continued growth of a much larger group of cancer cells. The disruption in the function of a single tumor blood vessel can result in an avalanche of ischemic cell death and necrosis of thousands of tumor cells which depend on it for blood supply. Thus, drugs that disrupt the ability of a tumor to induce or maintain an independent blood supply are promising cancer treatments.
Drugs that target tumor angiogenesis generally fall into one of two categories: anti-angiogenic drugs and dysangiogenic drugs. Anti-angiogenic drugs block the development and maintenance of new blood vessels, and thus impede tumor growth. An example of an anti-angiogenic drug is bevacizumab (Avastin®), an anti-vascular endothelial growth factor (VEGF) antibody. Dysangiogenic drugs, in contrast, result in disregulated angiogenesis, leading to the development of dysfunctional or nonfunctional vasculature.
The Notch pathway is involved in multiple aspects of vascular development including proliferation, migration, smooth muscle differentiation, angiogenesis and arterial-venous differentiation (Iso et al., 2003, Arterioscler. Thromb. Vase. Biol. 23:543). The Notch receptor ligand DLL4 (Delta-like ligand 4) is an important component of the Notch pathway and plays a role in angiogenesis. Heterozygous loss of DLL4 result in severe defects in arterial development and yolk sac vascularization, leading to embryonic lethality. (Duarte et al., 2004, Genes Dev., 18:2474-78; Gale et al., 2004, PNAS, 101:15949-54; Krebs et al., 2004, Genes Dev., 18:2469-73) Furthermore, tumor cells and tumor vasculature over express DLL4, suggesting that DLL4 expression is an important player in tumor angiogenesis. (Patel et al., 2005, Cancer Res., 65:8690-97; Yan et al., 2001, Blood, 98:3793-99) Thus, blocking DLL4 signaling has emerged as a promising avenue for the development of new anti-cancer therapies.
Blocking DLL4 signaling, such as by an anti-DLL4 antibody, has been shown to reduce tumor growth by multiple different mechanisms. (Ridgway et al., 2006, Nature, 444:1083-87; Noguera-Troise et al., Nature, 444:1032-37; Hoey et al., 2009, Cell Stem Cell, 5:168-77) For example, DLL4 blocking antibodies have been reported to result in endothelial cell proliferation and the development of blood vessels, however, these blood vessels lack a functional lumen. This dysangiogenic effect has been reported to block tumor growth by promoting the development of only non-functional blood vessels. (Ridgeway et al. and Noguera-Troise et al. (above); Scehnet et al., 2007, Blood, 109:4753-60) Additionally, DLL4 blocking antibodies have been shown to inhibit tumor growth by reducing the proliferation of tumor cells and reducing cancer stem cell frequency. Although the mechanism behind the reduction of tumor initiating cells (cancer stem cells, or CSCs) is unknown, it is hypothesized that DLL4 is required for the self-renewal of CSCs and maintains these cells in an undifferentiated state. (Hoey et al., above)
Unlike therapeutic approaches that attempt to block the signaling of tumor angiogenic factors, blockade of DLL4 signaling by anti-human DLL4 antibodies can result in endothelial hypertrophy and the creation of non-functional microvessels. Consequently, even in the presence of tumor angiogenic factors, blockade of DLL4 signaling, through administration of anti-human DLL4 antibodies, can result in dysangiogenesis which inhibits the ability of the tumor to induce the functional blood vessel formation needed to support growth of the tumor.
Anti-angiogenic drugs, such as the anti-VEGF antibody bevacizumab (Avastin®), sunitinib (Sutent®), and sorafenib (Nexavar®), are known to cause hypertension in about one-third of patients who take them. Although anti-Dll4 antibodies have been reported to inhibit tumor angiogenesis by promoting dysangiogenesis, a mechanism different than that of traditional anti-angiogenic treatments, the present inventors have now surprisingly found that an anti-Dll4 antibody can cause hypertension in some patients. Thus, there is a need for methods of treating cancer with a DLL4 antagonist, such as an anti-DLL4 antibody, while controlling the hypertension caused thereby.
It is a purpose of the invention to provide pharmaceutical compositions, methods, and kits for treating cancer with a DLL4 antagonist while controlling hypertension through the administration of one or more anti-hypertensive agents.
SUMMARY OF THE INVENTION
Provided are methods for treating cancer comprising administering to a subject in need thereof a DLL4 antagonist and one or more anti-hypertensive agents. Further provided are compositions and kits comprising a DLL4 antagonist and one or more anti-hypertensive agents. Also provided are methods of ameliorating hypertension in a patient receiving treatment with a DLL4 antagonist comprising administering to the patient an effective amount of one or more anti-hypertensive agents. Further provided are methods of preventing hypertension in a patient receiving treatment with a DLL4 antagonist comprising administering to the patient an effective amount of an anti-hypertensive agent. Also provided are methods of monitoring a patient receiving treatment with a DLL4 antagonist for the development of hypertension, comprising measuring the blood pressure of a patient receiving treatment with a DLL4 antagonist and administering to the patient with a blood pressure above normal range one or more anti-hypertensive agents.
In certain embodiments, the DLL4 antagonist is an antibody that specifically binds DLL4 (i.e., an anti-DLL4 antibody). In certain embodiments, the DLL4 to which the anti-DLL4 antibody binds is human DLL4. In one embodiment, the anti-DLL4 antibody is a monoclonal antibody. In a further embodiment, the anti-DLL4 antibody specifically binds to a human DLL4 epitope comprising amino acids within the human DLL4 N-terminal region comprising SEQ ID NO: 11. In other embodiments, the anti-DLL4 antibody is a humanized antibody or a human antibody. In a further embodiment, the humanized anti-DLL4 antibody is encoded by the plasmid deposited with ATCC on May 10, 2007, having ATCC deposit number PTA-8425, also known as 21M18 H7L2 and OMP-21M18. In a further embodiment, the humanized anti-DLL4 antibody is encoded by the plasmid deposited with ATCC on May 10, 2007, having ATCC deposit number PTA-8427, also known as 21M18 H9L2. In yet another embodiment, the anti-DLL4 antibody competes with the antibody OMP-21M18 for binding to DLL4.
In certain embodiments, the anti-hypertensive agent is selected from the group consisting of: diuretics, adrenergic receptor antagonists, adrenergic receptor agonists, calcium channel blockers, ACE inhibitors, angiotensin II receptor antagonists, aldosterone antagonists, vasodilators, renin inhibitors, and combinations thereof.
Administration of the DLL4 antagonist and one or more anti-hypertensive agents can be simultaneous or sequential. When administered sequentially, either the DLL4 antagonist or the anti-hypertensive agent can be administered first. In certain embodiments, administration of the DLL4 antagonist and anti-hypertensive agent is chronic; that is, the subject receiving treatment will be given multiple doses of the DLL4 antagonist and the anti-hypertensive agent over an extended period of time.
The subject in need of treatment suffers from cancer and can either suffer from hypertension, be at risk for developing hypertension, or is a subject in which the prevention or inhibition of hypertension is desirable. In certain embodiments, the subject in need of treatment is at risk for cardiovascular disease. In other embodiments, the subject in need of treatment cannot otherwise be treated with an appropriate, effective dose of a DLL4 antagonist without developing hypertension. In other embodiments, the subject does not have a prior history of hypertension and/or cardiovascular disease.
The invention also provides kits comprising a container, wherein the container contains therein a pharmaceutical composition comprising a DLL4 antagonist and a pharmaceutically acceptable carrier, and wherein the container further comprises a package insert indicating that the composition can be used in combination with one or more anti-hypertensive agents. In certain embodiments, the kit comprises an anti-DLL4 antibody and a package insert contained within a container. In other embodiments, the kit comprises an anti-DLL4 antibody, at least one anti-hypertensive agent, and a package insert contained within a container.
Additional objects and advantages of the invention will be set forth in part in the description which follows, and in part will be obvious from the description, or can be learned by practice of the invention. The objects and advantages of the invention will be realized and attained by means of the elements and combinations particularly pointed out in the appended claims. It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the invention, as claimed. In the specification and the appended claims, the singular forms “a,” “an,” and “the” include plural reference unless the context clearly dictates otherwise.



DESCRIPTION OF THE FIGURES
FIGS. 1A-1B: The Table of FIGS. 1A-1B is a summary of the blood pressure readings and anti-hypertensive treatments of Subject 1, a 78-year-old male with adenocarcinoma of the caecum with metastases to the liver, throughout a Phase I clinical trial of OMP-21M18. Subject 1 was enrolled in the 0.5 mg/kg OMP-21M18 cohort.
FIGS. 2A-2C: The Table of FIGS. 2A-2C is a summary of the blood pressure readings and anti-hypertensive treatments of Subject 2, a 55-year-old male with low-grade leiomyosarcoma, throughout a Phase I clinical trial of OMP-21M18. Subject 2 was enrolled in the 1.0 mg/kg OMP-21M18 cohort.
FIG. 3: The Table of FIG. 3 is a summary of the blood pressure readings and anti-hypertensive treatments of Subject 3, a 64-year-old woman with a choroidal melanoma of the right eye and metastases in both the liver and the lung, throughout a Phase I clinical trial of OMP-21M18. Subject 3 was enrolled in the 2.5 mg/kg OMP-21M18 cohort.
FIG. 4: The Table of FIG. 4 is a summary of the blood pressure readings and anti-hypertensive treatments of Subject 5, a 56-year-old female with stage IV colorectal cancer, throughout a Phase I clinical trial of OMP-21M18. Subject 5 was enrolled in the 10 mg/kg OMP-21M18 cohort.
FIG. 5: The Table of FIG. 5 is a summary of the blood pressure readings and anti-hypertensive treatments of Subject 7, a 71-year-old female with stage IV adenocarcinoma of the rectosigmoid junction, throughout a Phase I clinical trial of OMP-21M18. Subject 7 was enrolled in the 10 mg/kg OMP-21M18 cohort.
FIG. 6: The Table of FIG. 6 is a summary of the blood pressure readings and anti-hypertensive treatments of Subject 8, a 58-year-old man with stage IV colorectal cancer, throughout a Phase I clinical trial of OMP-21M18. Subject 8 was enrolled in the 10 mg/kg OMP-21M18 cohort.
FIG. 7: The Table of FIG. 7 is a summary of the blood pressure readings and anti-hypertensive treatments of Subject 9, a 54-year-old man with locally advanced adenocarcinoma of the head of the pancreas, throughout a Phase I clinical trial of OMP-21M18. Subject 9 was enrolled in the 10 mg/kg OMP-21M18 cohort.



All of the tables in FIGS. 1-7 include the baseline blood pressure of each subject, before the start of treatment with OMP-21M18, and blood pressure readings for each subject for every day of the study that blood pressure readings were taken. For study days in which an infusion of OMP-21M18 was administered, blood pressure readings include a reading pre-infusion, 15 minutes after the start of infusion, at the end of infusion, and 15 minutes post-infusion.
DESCRIPTION OF THE EMBODIMENTS
Definitions
The term “antibody” is used to mean an immunoglobulin molecule that recognizes and specifically binds to a target, such as a protein, polypeptide, peptide, carbohydrate, polynucleotide, lipid, or combinations of the foregoing through at least one antigen recognition site within the variable region of the immunoglobulin molecule. In certain embodiments, antibodies of the present invention include antagonist antibodies that specifically bind to DLL4. Such antibodies can, for example, interfere with ligand binding, receptor dimerization, and/or downstream signaling of the DLL4 receptor.
As used herein, the term “antibody” encompasses intact polyclonal antibodies, intact monoclonal antibodies, antibody fragments (such as Fab, Fab′, F(ab′)2, and Fv fragments), single chain Fv (scFv) mutants, multispecific antibodies such as bispecific antibodies generated from at least two intact antibodies, chimeric antibodies, humanized antibodies, human antibodies, fusion proteins comprising an antigen determination portion of an antibody, and any other modified immunoglobulin molecule comprising an antigen recognition site so long as the antibodies exhibit the desired biological activity. An antibody can be of any the five major classes of immunoglobulins: IgA, IgD, IgE, IgG, and IgM, or subclasses (isotypes) thereof (e.g. IgG1, IgG2, IgG3, IgG4, IgA1 and IgA2), based on the identity of their heavy-chain constant domains referred to as alpha, delta, epsilon, gamma, and mu, respectively. The different classes of immunoglobulins have different and well known subunit structures and three-dimensional configurations. Antibodies can be naked or conjugated to other molecules such as toxins, radioisotopes, etc.
A “monoclonal antibody” as used herein refers to homogenous antibody population involved in the highly specific recognition and binding of a single antigenic determinant, or epitope. This is in contrast to polyclonal antibodies that typically include different antibodies directed against different antigenic determinants. The term “monoclonal antibody” encompasses both intact and full-length monoclonal antibodies as well as antibody fragments (such as Fab, Fab′, F(ab′)2, Fv), single chain (scFv) mutants, fusion proteins comprising an antibody portion, and any other modified immunoglobulin molecule comprising an antigen recognition site. Furthermore, “monoclonal antibody” refers to such antibodies made in any number of manners including but not limited to by hybridoma, phage selection, recombinant expression, and transgenic animals.
As used herein, the term “humanized antibody” refers to forms of non-human (e.g. murine) antibodies that are specific immunoglobulin chains, chimeric immunoglobulins, or fragments thereof that contain minimal non-human sequences. Typically, humanized antibodies are human immunoglobulins in which residues from the complementarity determining regions (CDRs) within the antigen determination region (or hypervariable region) of the variable region of an antibody chain or chains are replaced by residues from the CDR of a non-human species (e.g. mouse, rat, rabbit, hamster) that have the desired specificity, affinity, and capability. In some instances, residues from the variable chain framework region (FR) of a human immunoglobulin are replaced with the corresponding residues in an antibody from a non-human species that has the desired specificity, affinity, and capability. The humanized antibody can be further modified by the substitution of additional residues either in the variable framework region and/or within the replaced non-human residues to refine and optimize antibody specificity, affinity, and/or capability. In general, the humanized antibody will comprise substantially all of at least one, and typically two or three or four, variable domains containing all or substantially all of the CDR regions that correspond to the non-human immunoglobulin whereas all or substantially all of the FR regions are those of a human immunoglobulin consensus sequence. The humanized antibody can also comprise at least a portion of an immunoglobulin constant region or domain (Fc), typically that of a human immunoglobulin. Examples of methods used to generate humanized antibodies are described in U.S. Pat. No. 5,225,539.
The term “human antibody,” as used herein, means an antibody produced by a human or an antibody having an amino acid sequence corresponding to an antibody produced by a human made using any technique known in the art. This definition of a human antibody includes intact or full-length antibodies, fragments thereof, and/or antibodies comprising at least one human heavy and/or light chain polypeptide such as, for example, an antibody comprising murine light chain and human heavy chain polypeptides.
That an antibody “selectively binds” or “specifically binds” means that the antibody reacts or associates more frequently, more rapidly, with greater duration, with greater affinity, or with some combination of the above to an epitope than with alternative substances, including unrelated proteins. “Selectively binds” or “specifically binds” means that an antibody binds to a protein at times with a KD of about 0.1 mM or lower, and at other times about 0.01 mM or lower. Because of the sequence identity between homologous proteins in different species, specific binding can include an antibody that recognizes a DLL4 protein in more than one species.
The terms “epitope” or “antigenic determinant” are used interchangeably herein and refer to that portion of an antigen capable of being recognized and specifically bound by a particular antibody. When the antigen is a polypeptide, epitopes can be formed both from contiguous amino acids and noncontiguous amino acids juxtaposed by tertiary folding of a protein. Epitopes formed from contiguous amino acids are typically retained upon protein denaturing, whereas epitopes formed by tertiary folding are typically lost upon protein denaturing. An epitope typically includes at least 3, and more usually, at least 5 or 8-10 amino acids in a unique spatial conformation.
As used herein, the term “hypertension” refers to a condition in which a subject exhibits abnormally elevated blood pressure. Hypertension is classified as either essential hypertension (primary hypertension), in which no specific medical cause for the elevated blood pressure is found, or secondary hypertension, in which elevated blood pressure is due to a specific condition, such as kidney disease or tumors, or due to exposure to a substance that increases blood pressure. In general, hypertension in humans is considered to be present when a person's blood pressure is consistently at least 140 mmHg systolic or 90 mmHg diastolic. Prehypertension is considered to be present when a person's blood pressure is in the range of 120-139 mmHg systolic or 80-89 mmHg diastolic. While not necessarily problematic in itself, prehypertension can indicate that a person is at increased risk for developing hypertension.
As used herein, the term “anti-hypertensive agent” refers to any compound that when administered to a subject reduces blood pressure. In medicine, anti-hypertensive drugs are used to treat hypertension. There are several classes of anti-hypertensive drugs, including diuretics, adrenergic receptor antagonists, adrenergic receptor agonists, calcium channel blockers, ACE inhibitors, angiotensin II receptor antagonists, aldosterone antagonists, vasodilators, and renin inhibitors. Each of these groups of anti-hypertensive drugs acts to reduce blood pressure through a different mechanism.
As used herein, the terms “cancer” and “cancerous” refer to or describe the physiological condition in mammals in which a population of cells are characterized by unregulated cell growth. Examples of cancer include, but are not limited to, carcinoma, lymphoma, blastoma, sarcoma, and leukemia. More particular examples of solid tumor cancers include squamous cell cancer, small-cell lung cancer, non-small cell lung cancer, adenocarcinoma of the lung, squamous carcinoma of the lung, cancer of the peritoneum, hepatocellular cancer, gastrointestinal cancer, pancreatic cancer, glioblastoma, cervical cancer, ovarian cancer, liver cancer, bladder cancer, hepatoma, breast cancer, colon cancer, colorectal cancer, endometrial or uterine carcinoma, salivary gland carcinoma, kidney cancer, liver cancer, prostate cancer, vulval cancer, thyroid cancer, hepatic carcinoma, and various types of head and neck cancers.
As used herein, the terms “subject” or “patient” refers to any animal (e.g., a mammal), including, but not limited to humans, non-human primates, rodents, and the like, which is to be the recipient of a particular treatment. Typically, the teens “subject” and “patient” are used interchangeably herein in reference to a human subject.
“Pharmaceutically acceptable carrier, excipient, or adjuvant” refers to a carrier, excipient, or adjuvant that can be administered to a subject together with the anti-DLL4 antibody and/or one or more anti-hypertensive agent of the invention, and which does not destroy the pharmacological activity thereof and is nontoxic when administered in doses sufficient to deliver a therapeutic amount of the compound. Pharmaceutically acceptable carriers, excipients or adjuvants are often listed in the U.S. Pharmacopeia or other generally recognized pharmacopeia for use in animals, including humans.
The terms “effective amount” or “therapeutically effective amount” refers to an amount of an antibody, polypeptide, polynucleotide, small organic molecule, or other drug effective to “treat” a disease or disorder in a subject or mammal. In the case of cancer, the therapeutically effective amount of the drug can reduce the number of cancer cells; reduce the tumor size; inhibit or stop cancer cell infiltration into peripheral organs including, for example, the spread of cancer into soft tissue and bone; inhibit and stop tumor metastasis; inhibit and stop tumor growth; relieve to some extent one or more of the symptoms associated with the cancer, reduce morbidity and mortality; improve quality of life; or a combination of such effects. To the extent the drug prevents growth and/or kills existing cancer cells, it can be referred to as cytostatic and/or cytotoxic. In the case of hypertension, a therapeutically effective amount of the anti-hypertensive agent can reduce the blood pressure of a subject or prevent a subject's blood pressure from rising. Preferably, the therapeutically effective amount of the anti-hypertensive agent will reduce a subject's blood pressure to clinically defined “normal” levels or maintain a subject's blood pressure within normal bounds.
Terms such as “treating” or “treatment” or “to treat” or “alleviating” or “to alleviate” or “ameliorating” or “to ameliorate” refer to both 1) therapeutic measures that cure, slow down, lessen symptoms of, and/or halt progression of a diagnosed pathologic condition or disorder and 2) prophylactic or preventative measures that prevent and/or slow the development of a targeted pathologic condition or disorder. Thus those in need of treatment include those already with the disorder; those prone to have the disorder; and those in whom the disorder is to be prevented. In certain embodiments, a subject is successfully “treated” according to the methods of the present invention if the patient shows one or more of the following: a reduction in the number of or complete absence of cancer cells; a reduction in the tumor size; inhibition of or an absence of cancer cell infiltration into peripheral organs including, for example, the spread of cancer into soft tissue and bone; inhibition of or an absence of tumor metastasis; inhibition or an absence of tumor growth; relief of one or more symptoms associated with the specific cancer; reduced morbidity and mortality; improvement in quality of life; a reduction in blood pressure or stable maintenance of blood pressure at or about clinically normal levels; or some combination of effects.
DLL4 Antibodies
In certain embodiments, the DLL4 antagonists are antibodies, such as antibodies that bind specifically to DLL4 (i.e., anti-DLL4 antibodies). In certain embodiments, the antibodies specifically bind human DLL4.
Anti-DLL4 antibodies can act as DLL4 antagonists by binding to DLL4 and blocking its binding to the Notch receptor. The DLL4 antibodies of the invention can be prepared by any conventional means known in the art. In certain embodiments, the Dll4 antibodies are dysangiogenic.
In certain embodiments, the anti-DLL4 antibody is a monoclonal antibody. Monoclonal antibodies can be prepared by any conventional means known in the art (Goding, Monoclonal Antibodies: Principles and Practice, Academic Press, 1986). Monoclonal antibodies can be prepared using hybridoma methods, such as those described by Kohler and Milstein (1975) Nature 256:495. Alternatively, monoclonal antibodies can also be made using recombinant DNA methods as described in U.S. Pat. No. 4,816,567. Recombinant monoclonal antibodies or fragments thereof of the desired species can also be isolated from phage display libraries expressing CDRs of the desired species as described (McCafferty et al., 1990, Nature, 348:552-554; Clackson et al., 1991, Nature, 352:624-628; and Marks et al., 1991, J. Mol. Biol., 222:581-597).
In some embodiments of the present invention, the anti-DLL4 antibody is a humanized antibody. Humanized antibodies are antibodies that contain minimal sequences from non-human (e.g murine) antibodies within the variable regions. Such antibodies are used therapeutically to reduce antigenicity and HAMA (human anti-mouse antibody) responses when administered to a human subject. Humanized antibodies can be produced using various techniques known in the art (Jones et al., 1986, Nature, 321:522-525; Riechmann et al., 1988, Nature, 332:323-327; Verhoeyen et al., 1988, Science, 239:1534-1536). An antibody can be humanized by substituting the CDRs of a human antibody with that of a non-human antibody (e.g. mouse, rat, rabbit, hamster, etc.) having the desired specificity, affinity, and/or capability. The humanized antibody can be further modified by the substitution of additional residue either in the variable human framework region and/or within the replaced non-human residues to refine and optimize antibody specificity, affinity, and/or capability.
In other embodiments, the anti-DLL4 antibody is a fully human antibody. Human antibodies can be prepared using various techniques known in the art. Immortalized human B lymphocytes immunized in vitro or isolated from an immunized individual that produce an antibody directed against a target antigen can be generated (See, e.g., Cole et al., Monoclonal Antibodies and Cancer Therapy, Alan R. Liss, p. 77 (1985); Boerner et al., 1991, J. Immunol., 147 (1):86-95; and U.S. Pat. No. 5,750,373). Also, the human antibody can be selected from a phage library, where that phage library expresses human antibodies (Vaughan et al., 1996, Nat. Biotech., 14:309-314; Sheets et al., 1998, Proc. Nat'l. Acad. Sci., 95:6157-6162; Hoogenboom and Winter, 1991, J. Mol. Biol., 227:381; Marks et al., 1991, J. Mol. Biol., 222:581). Human antibodies can also be made in transgenic mice containing human immunoglobulin loci that are capable upon immunization of producing the full repertoire of human antibodies in the absence of endogenous immunoglobulin production. This approach is described in U.S. Pat. Nos. 5,545,807; 5,545,806; 5,569,825; 5,625,126; 5,633,425; and 5,661,016.
In certain embodiments, the anti-DLL4 antibody specifically binds to a human DLL4 epitope in the amino-terminal region (SEQ ID NO: 11). In certain embodiments, the anti-Dll4 antibody binds to the DSL domain. In certain embodiments, the anti-Dll4 antibody binds to both the DSL domain and/or the amino-terminal region of Dll4.
In certain embodiments, the anti-DLL4 antibody is the antibody produced by the hybridoma deposited with ATCC on Sep. 28, 2007 and having ATCC deposit number PTA-8670, also known as murine 21M18. The murine 21M18 antibody is described in detail in co-pending U.S. patent application Ser. No. 11/905,392, Publication No. 2008/0187532, filed Sep. 28, 2007, incorporated herein by reference in its entirety.
In certain embodiments, the anti-DLL4 antibody is the antibody encoded by the plasmid deposited with ATCC, 10801 University Boulevard, Manassas, Va., USA, on May 10, 2007, having ATCC deposit number PTA-8425, also known as 21M18 H7L2 and OMP-21M18. The OMP-21M18 antibody is described in detail in co-pending U.S. patent application Ser. No. 11/905,392, Publication No. 2008/0187532, filed Sep. 28, 2007. The anti-DLL4 antibody OMP-21M18 comprises a heavy chain variable region comprising CDR amino acid sequences CDR1 (SEQ ID NO: 1); CDR2 (SEQ ID NO: 2, SEQ ID NO: 3, or SEQ ID NO: 4); and CDR3 (SEQ ID NO: 5); and a light chain variable region comprising CDR amino acid sequences CDR1 (SEQ ID NO: 7); CDR2 (SEQ ID NO: 8); and CDR3 (SEQ ID NO: 9). In one embodiment, the OMP-21M18 antibody comprises the heavy chain sequence of SEQ ID NO:6 and the light chain sequence of SEQ ID NO: 10.
In certain embodiments, the anti-DLL4 antibody is the antibody encoded by the plasmid deposited with ATCC on May 10, 2007, having ATCC deposit number PTA-8427, also known as 21M18 H9L2. The 21M18 H9L2 antibody is described in detail in co-pending U.S. patent application Ser. No. 11/905,392, Publication No. 2008/0187532, filed Sep. 28, 2007.
In certain embodiments, the anti-DLL4 antibody is an antibody that competes with the antibody OMP-21M18 for specific binding to human DLL4.
Other anti-DLL4 antibodies are known in the art. Anti-DLL4 antibodies are available from commercial sources (for example, Santa Cruz Biotechnology, Inc. catalog no. sc-73900 is a rat IgG2a antibody that binds to the extracellular domain of human DLL4). In some embodiments, the DLL4 antagonist can be one of the anti-DLL4 antibodies described in U.S. patent application Ser. No. 12/002,245, filed Dec. 14, 2007, and published as U.S. Patent Application Pub. No. 2008/0181899; U.S. Pat. No. 7,488,806, filed Oct. 3, 2008, and published as U.S. Patent Application Pub. No. 2009/0017035; and U.S. Pat. No. 7,534,868, filed Feb. 13, 2009, and published as U.S. Patent Application Pub. No. 2009/0142354. The foregoing patents and applications disclose fully human anti-DLL4 antibodies generated using VELOCIMMUNETM technology (Regeneron Pharmaceuticals, Inc.). Certain of these antibodies, denoted REGN281, REGN 421, and REGN 422 are described as blocking DLL4 binding to the Notch receptor.
In other embodiments, the DLL4 antagonist can be one of the anti-DLL4 antibodies described in U.S. patent application Ser. No. 11/759,131, filed Jun. 6, 2007, and published as U.S. Patent Application Pub. No. 2008/0175847; and U.S. patent application Ser. No. 11/759,093, filed Jun. 6, 2007, and published as U.S. Patent Application Pub. No. 2008/0014196 (now abandoned). The foregoing applications disclose human anti-DLL4 antibodies that are described as binding to the extracellular domain of DLL4. These antibodies were isolated by screening a synthetic phage antibody library (Genentech, Inc.).
Anti-Hypertensive Agents
The anti-hypertensive agents useful in the present invention fall into several classes, including: diuretics, adrenergic receptor antagonists, adrenergic receptor agonists, calcium channel blockers, Angiotensin-Converting Enzyme (ACE) inhibitors, angiotensin II receptor antagonists, aldosterone antagonists, vasodilators, and renin inhibitors.
Diuretics are a class of drugs that elevate the rate of urination and thus provides a means of forced diuresis. There are several categories of diuretics, including high ceiling loop diuretics, thiazides, potassium-sparing diuretics, calcium-sparing diuretics, osmotic diuretics, and low ceiling diuretics. All diuretics increase the excretion of water from the body, although each class does so in a distinct way. Diuretics include but are not limited to: loop diuretics such as furosemide, bumetanide, ethacrynic acid, and torsemide; thiazide diuretics such as epitizide, hydrochlorothiazide, hydroflumethiazide, chlorothiazide, bendroflumethiazide, polythiazide, trichlormethiazide, cyclopenthiazide, methyclothiazide, cyclothiazide, mebutizide, and other benzothiadiazine derivatives; thiazide-like diuretics such as indapamide, chlortalidone, metolazone, quinethazone, clopamide, mefruside, clofenamide, meticrane, xipamide, clorexolone, and fenquizone; potassium-sparing diuretics such as amiloride, triamterene, eplerenone, benzamil, potassium canrenoate, canrenone, and spironolactone; osmotic diuretics such as mannitol, glucose, and urea; vasopressin receptor antagonists such as conivaptan, relcovaptan, nelivaptan, lixivaptan, mozavaptan, satavaptan, tolvaptan, and demeclocycline; mercurial diuretics such as mersalyl acid (Mersal), meralluride, mercaptomerin, mercurophylline, merethoxylline procaine, and calomel; xanthine diuretics such as caffeine, theobromine, paraxanthine, and theophylline; carbonic anhydrase inhibitors such as acetazolamide, methazolamide, dorzolamide, sulfonamide, and topiramate; other diuretics such as diuretic purines, diuretic steroids, diuretic sulfonamide derivatives, diuretic uracils, amanozine, arbutin, chlorazanil, etozolin, hydracarbazine, isosorbide, metochalcone, muzolimine, perhexyline, ticrynafen, triamterene, and spironolactone.
Adrenergic receptor antagonists can be divided into two sub-categories: beta-adrenergic antagonists (“beta blockers”) and alpha-adrenergic antagonists (“alpha blockers”). Adrenergic receptor antagonists include but are not limited to: beta-adrenergic antagonists such as atenolol, metoprolol, nadolol, oxprenolol, pindolol, propranolol, timolol, acebutolol, bisoprolol, esmolol, labetalol, carvedilol, bucindolol, nebivolol, alprenolol; amosulalol, arotinolol, befunolol, betaxolol, bevantolot, bopindolol, bucumolol, bufetolol, bufuralol, bunitrolol, bupranolol, butidrine hydrochloride, butofilolol, carazolol, carteolol, celiprolol, cetamolol, cloranololdilevalol, epanolol, indenolol, levobunolol, mepindolol, metipranolol, moprolol, nadoxolol, nipradilol, penbutolol, practolol, pronethalol, sotalol, sulfinalol, talinolol, tertatolol, tilisolol, toliprolol, and xibenolol; and alpha-adrenergic antagonists such as phenoxybenzamine, prazosin, doxazosin, terazosin, trimazosin, phentolamine, amosulalol, arotinolol, dapiprazole, fenspiride, indoramin, labetalol, naftopidil, nicergoline, tamsulosin, tolazoline, reserpine, moxonidine and yohimbine.
Adrenergic receptor agonists include but are not limited to: clonidine, methyldopa, guanfacine, methoxamine, methylnorepinephrine, oxymetazoline, phenylephrine, guanabenz, guanoxabenz, guanethidine, xylazine, and tizanidine.
Calcium channel blockers block voltage-gated calcium channels in cardiac muscle and blood vessels, leading to a reduction in muscle contraction. This leads to vasodilation and a decrease in blood pressure. Calcium channel blockers include but are not limited to: dihydropyridines such as amlodipine, felodipine, nicardipine, nifedipine, nimodipine, isradipine, nitrendipine, aranidipine, barnidipine, benidipine, cilnidipine, efonidipine, elgodipine, lacidipine, lercanidipine, manidipine, nilvadipine, and nisoldipine; and non-dihydropyridines such as diltiazem, verapamil, bepridil, clentiazem, fendiline, gallopamil, mibefradil, prenylamine, semotiadil, terodiline, cinnarizine, flunarizine, lidoflazine, lomerizine, bencyclane, etafenone, and perhexyline.
Angiotensin-Converting Enzyme (ACE) inhibitors treat hypertension by lowering arteriolar resistance and increasing venous capacity, increasing cardiac output and cardiac index, stroke work and volume, lowering renovascular resistance, and increasing excretion of sodium in the urine. ACE inhibitors include but are not limited to: sulfhydryl-containing agents such as captopril and zofenopril; dicarboxylate-containing agents such as enalapril, ramipril, quinapril, perindopril, lisinopril, and benazepril; phosphonate-containing agents such as fosinopril and ceronapril, naturally occurring ACE inhibitors such as casokinins, lactokinins; tripeptides such as Val-Pro-Pro and Ile-Pro-Pro and the nonapeptide teprotide; and other ACE inhibitors such alacepril, cilazapril, delapril imidapril moexipril, rentiapril, spirapril, temocapril, moveltipril and trandolapril.
Angiotensin II receptor antagonists block the activation of angiotensin II AT1 receptors, causing vasodilation, reduced secretion of vasopressin, and reduced production and secretion of aldosterone, which results in the reduction of blood pressure. Angiotensin II receptor antagonists include but are not limited to: candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, and valsartan.
Aldosterone antagonists block the mineralocorticoid receptor resulting in inhibition of sodium resorption in the collecting duct of the nephron in the kidneys. This interferes with sodium/potassium exchange, reducing urinary potassium excretion and weakly increasing water excretion, leading to a diuretic effect. Aldosterone antagonists include but are not limited to: eplerenone, canrenone, and spironolactone.
Vasodilators work by a wide variety of mechanisms, but all lead to the relaxation of smooth muscle cells within blood vessel walls, and thus the widening of blood vessels. The widening of blood vessels leads to increased blood flow and reduced vascular resistance, and therefore lower blood pressure. Vasodilators include but are not limited to: cerebral vasodilators such as bencyclane, cinnarizine, citicoline, cyclandelate, ciclonicate, diisopropylamine dichloroacetate, eburnamonine, fasudil, fenoxedil, flunarizine, ibudilast, ifenprodil, lomerizine, nafronyl, nicametate, nicergoline, nimodipine, papaverine, tinofedrine, vincamine, vinpocetine, and viquidil; coronary vasodilators such as amotriphene, bendazol, benfurodil hemisuccinate, benziodarone, chloracizine, chromonar, clobenfural, clonitrate, cloricromen, dilazep, dipyridamole, droprenilamine, efloxate, erythrityl tetranitrate, etafenone, fendiline, floredil, ganglefene, hexestrol bis(β-diethylaminoethyl)ether, hexobendine, itramin tosylate, khellin, lidoflazine, mannitol hexanitrate, medibazine, nitroglycerin, pentaerythritol tetranitrate, pentrinitrol, perhexyline, pimethylline, prenylamine, propatyl nitrate, trapidil, tricromyl, trimetazidine, trolnitrate phosphate, sildenafil, tadalafil, vardenafil, sodium nitroprusside, isosorbide mononitrate, isosorbide dinitrate, pentaerythritol tetranitrate, theobromine, and visnadine; and peripheral vasodilators such as aluminium nicotinate, bamethan, bencyclane, betahistine, bradykinin, brovincamine, bufeniode, buflomedil, butalamine, cetiedil, ciclonicate, cinepazide, cinnarizine, cyclandelate, diisopropylamine dichloroacetate, eledoisin, fenoxedil, flunarizine, hepronicate, ifenprodil, iloprost, inositol niacinate, isoxsuprine, kallidin, kallikrein, moxisylyte, nafronyl, nicametate, nicergoline, nicofuranose, nylidrin, pentifylline, pentoxifylline, piribedil, prostaglandin E1, suloctidil, tolazoline, and xanthinol niacinate.
Renin inhibitors act on the juxtaglomerular cells of kidney, which produce renin in response to decreased blood flow. Renin inhibitors include but are not limited to: aliskiren and remikiren.
Other anti-hypertensives, not listed above, are also contemplated for use in the invention. A skilled artisan would recognize that any compound that acts to reduce blood pressure when administered to a subject could be used as the anti-hypertensive agent of the present invention.
Pharmaceutical Composition
The pharmaceutical compositions of the present invention comprise an anti-DLL4 antibody and one or more anti-hypertensive agents. The pharmaceutical compositions of the present invention can be prepared for storage and use by combining an anti-DLL4 antibody and one or more anti-hypertensive agent with a pharmaceutically acceptable carrier (e.g. a vehicle or excipient). In other embodiments, the anti-DLL4 antibody and the one or more anti-hypertensive agents are in separate compositions, wherein those compositions are each formulated with pharmaceutically acceptable carriers appropriate for each agent.
Examples of suitable pharmaceutical carriers are described in “Remington, The Science and Practice of Pharmacy 20th Edition Mack Publishing, 2000.” Suitable pharmaceutically acceptable vehicles include, but are not limited to, nontoxic buffers such as phosphate, citrate, and other organic acids; salts such as sodium chloride; antioxidants including ascorbic acid and methionine; preservatives (e.g. octadecyldimethylbenzyl ammonium chloride; hexamethonium chloride; benzalkonium chloride; benzethonium chloride; phenol, butyl or benzyl alcohol; alkyl parabens, such as methyl or propyl paraben; catechol; resorcinol; cyclohexanol; 3-pentanol; and m-cresol); low molecular weight polypeptides (e.g. less than about 10 amino acid residues); proteins such as serum albumin, gelatin, or immunoglobulins; hydrophilic polymers such as polyvinylpyrrolidone; amino acids such as glycine, glutamine, asparagine, histidine, arginine, or lysine; carbohydrates such as monosaccharides, disaccharides, glucose, mannose, or dextrins; chelating agents such as EDTA; sugars such as sucrose, mannitol, trehalose or sorbitol; salt-forming counter-ions such as sodium; metal complexes (e.g. Zn-protein complexes); and non-ionic surfactants such as TWEEN, polyethylene glycol (PEG), or polysorbate surfactants such as Polysorbate 20.
The pharmaceutical compositions of the present invention can be formulated for systemic or local administration. Examples of routes of administration include parenteral (e.g., intravenous, intradermal, subcutaneous), oral (e.g., inhalation), transmucosal, and rectal administration.
Pharmaceutical compositions suitable for parenteral administration include sterile aqueous solutions (where water soluble) or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersion. For intravenous administration, suitable carriers include water for injection, physiological saline, bacteriostatic water, Cremophor EL (BASF, Parsippany, N.J.), phosphate buffered saline (PBS), fixed oils, ethanol, polyethylene glycols, glycerine, propylene glycol or other synthetic solvents. In all cases, the composition must be sterile and should be fluid to the extent that easy syringeability exists. The proper fluidity can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of a dispersion, and by the use of surfactants. The pharmaceutical composition must be stable under the conditions of manufacture and storage and must be preserved against the contaminating action of microorganisms such as bacteria and fungi. Prevention of the action of microorganisms can be achieved by various antibacterial and antifungal agents, for example, benzyl alcohol, parabens, chlorobutanol, phenol, antioxidants such as ascorbic acid or sodium bisulfite, chelating agents such as ethylenediaminetetraacetic acid, thimerosal, and the like. In many cases, it will be preferable to include isotonic agents such as sugars, polyalcohols such as mannitol and sorbitol, or sodium chloride in the composition. Prolonged absorption of the injectable compositions can be brought about by including in the composition an agent which delays absorption, for example, aluminum monostearate and gelatin. The pH can be adjusted with acids or bases, such as hydrochloric acid or sodium hydroxide. The parenteral preparation is enclosed in ampoules, disposable syringes or multiple dose vials made of glass or plastic.
Sterile injectable solutions are prepared by incorporating the active compound (e.g., an anti-DLL4 antibody and an anti-hypertensive agent) in the required amount in an appropriate solvent with one or a combination of ingredients enumerated above, as required, followed by filter sterilization. Generally, dispersions are prepared by incorporating the active compounds into a sterile vehicle that contains a basic dispersion medium and the required other ingredients from those enumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, methods of preparation are vacuum drying and freeze-drying that yield a powder of the active ingredient plus any additional desired ingredient from a previously sterile-filtered solution thereof.
In certain embodiments, the anti-DLL4 antibody can be prepared for use at a concentration of 10 mg/mL in a solution of 50 mM histidine, 100 mM sodium chloride, 45 mM sucrose, and 0.01% (w/v) Polysorbate 20, and the pH adjusted to 6.0.
The pharmaceutical compositions of the invention can include the anti-DLL4 antibody and/or anti-hypertensive agent complexed with liposomes (Epstein, et al., 1985, Proc. Natl. Acad. Sci. USA 82:3688; Hwang, et al., 1980, Proc. Natl. Acad. Sci. USA 77:4030; and U.S. Pat. Nos. 4,485,045 and 4,544,545). Liposomes with enhanced circulation time are disclosed in U.S. Pat. No. 5,013,556. Some liposomes can be generated by the reverse phase evaporation with a lipid composition comprising phosphatidylcholine, cholesterol, and PEG-derivatized phosphatidylethanolamine (PEG-PE). Liposomes are extruded through filters of defined pore size to yield liposomes with the desired diameter.
The anti-DLL4 antibody and/or the anti-hypertensive agent can also be entrapped in microcapsules. Such microcapsules are prepared, for example, by coacervation techniques or by interfacial polymerization, for example, hydroxymethylcellulose or gelatin-microcapsules and poly-(methylmethacylate) microcapsules, respectively, in colloidal drug delivery systems (for example, liposomes, albumin microspheres, microemulsions, nano-particles and nanocapsules) or in macroemulsions as described in “Remington, The Science and Practice of Pharmacy 20th Ed. Mack Publishing (2000).”
In addition sustained-release preparations can be prepared. Suitable examples of sustained-release preparations include semipermeable matrices of solid hydrophobic polymers containing the anti-DLL4 antibody and/or the anti-hypertensive agent, which matrices are in the form of shaped articles (e.g. films, or microcapsules). Examples of sustained-release matrices include polyesters, hydrogels such as poly(2-hydroxyethyl-methacrylate) or poly(vinylalcohol), polylactides (U.S. Pat. No. 3,773,919), copolymers of L-glutamic acid and 7 ethyl-L-glutamate, non-degradable ethylene-vinyl acetate, degradable lactic acid-glycolic acid copolymers such as the LUPRON DEPOTTM (injectable microspheres composed of lactic acid-glycolic acid copolymer and leuprolide acetate), sucrose acetate isobutyrate, and poly-D-(−)-3-hydroxybutyric acid.
Oral compositions generally include an inert diluent or an edible carrier. They can be enclosed in gelatin capsules or compressed into tablets. For the purpose of oral therapeutic administration, the active compound is incorporated with excipients and used in the form of tablets, troches, or capsules. Pharmaceutically compatible binding agents, and/or adjuvant materials can be included as part of the composition. The tablets, pills, capsules, troches and the like can contain any of the following ingredients, or compounds of a similar nature: a binder such as microcrystalline cellulose, gum tragacanth or gelatin; an excipient such as starch or lactose, a disintegrating agent such as alginic acid, Primogel, or corn starch; a lubricant such as magnesium stearate or Sterotes; a glidant such as colloidal silicon dioxide; a sweetening agent such as sucrose or saccharin; or a flavoring agent such as peppermint, methyl salicylate, or orange flavoring. The tablets, pills, etc of the novel composition can be coated or otherwise compounded to provide a dosage form affording the advantage of prolonged action. For example, the tablet or pill can comprise an inner composition covered by an outer component. Furthermore, the two components can be separated by an enteric layer that serves to resist disintegration and permits the inner component to pass intact through the stomach or to be delayed in release. A variety of materials can be used for such enteric layers or coatings, such materials including a number of polymeric acids and mixtures of polymeric acids with such materials as shellac, cetyl alcohol and cellulose acetate.
For administration by inhalation, the compounds are delivered in the form of an aerosol spray from a pressured container or dispenser which contains a suitable propellant, e.g., a gas such as carbon dioxide, or a nebulizer.
Administration can also be transmucosal or transdermal. For transmucosal or transdermal administration, penetrants appropriate to the barrier to be permeated are used in the formulation. Such penetrants are generally known in the art, and include, for example, for transmucosal administration, detergents, bile salts, and fusidic acid derivatives. Transmucosal administration can be accomplished through the use of nasal sprays or suppositories. For transdermal administration, the active compounds are formulated into ointments, salves, gels, or creams as generally known in the art.
Combination Therapies
In certain embodiments, the anti-DLL4 antibody and the anti-hypertensive agent can be administered in combination with one or more additional compounds or therapies for the treatment of cancer. Such additional anti-cancer compounds include: cytotoxic agents, chemotherapeutic agents, growth inhibitory agents, or therapeutic antibodies. Where separate pharmaceutical compositions are used, the anti-DLL4 antibody and one or more additional agents can be administered concurrently, or sequentially.
“Cytotoxic agents” inhibit or prevent the function of cells and/or causes destruction of cells. Cytotoxic agents include but are not limited to: radioactive isotopes (e.g. I131, I125, Y90 and Re186), and toxins such as enzymatically active toxins of bacterial, fungal, plant or animal origin, or fragments thereof.
“Chemotherapeutic agents” are chemical compounds useful in the treatment of cancer. Chemotherapeutic agents include but are not limited to: alkylating agents such as thiotepa and cyclosphosphamide (CYTOXANTM); alkyl sulfonates such as busulfan, improsulfan and piposulfan; aziridines such as benzodopa, carboquone, meturedopa, and uredopa; ethylenimines and methylamelamines including altretamine, triethylenemelamine, trietylenephosphoramide, triethylenethiophosphaoramide and trimethylolomelamine; nitrogen mustards such as chlorambucil, chlornaphazine, cholophosphamide, estramustine, ifosfamide, mechlorethamine, mechlorethamine oxide hydrochloride, melphalan, novembichin, phenesterine, prednimustine, trofosfamide, uracil mustard; nitrosureas such as carmustine, chlorozotocin, fotemustine, lomustine, nimustine, ranimustine; antibiotics such as aclacinomysins, actinomycin, authramycin, azaserine, bleomycins, cactinomycin, calicheamicin, carabicin, caminomycin, carzinophilin, chromomycins, dactinomycin, daunorubicin, detorubicin, 6-diazo-5-oxo-L-norleucine, doxorubicin, epirubicin, esorubicin, idarubicin, marcellomycin, mitomycins, mycophenolic acid, nogalamycin, olivomycins, peplomycin, potfiromycin, puromycin, quelamycin, rodorubicin, streptonigrin, streptozocin, tubercidin, ubenimex, zinostatin, zorubicin; anti-metabolites such as methotrexate and 5-fluorouracil; folic acid analogues such as denopterin, methotrexate, pteropterin, trimetrexate; purine analogs such as fludarabine, 6-mercaptopurine, thiamiprine, thioguanine; pyrimidine analogs such as ancitabine, azacitidine, 6-azauridine, carmofur, cytarabine, dideoxyuridine, doxifluridine, enocitabine, floxuridine; androgens such as calusterone, dromostanolone propionate, epitiostanol, mepitiostane, testolactone; anti-adrenals such as aminoglutethimide, mitotane, trilostane; folic acid replenisher such as frolinic acid; aceglatone; aldophosphamide glycoside; aminolevulinic acid; amsacrine; bestrabucil; bisantrene; edatraxate; defofamine; demecolcine; diaziquone; elformithine; elliptinium acetate; etoglucid; gallium nitrate; hydroxyurea; lentinan; lonidamine; mitoguazone; mitoxantrone; mopidamol; nitracrine; pentostatin; phenamet; pirarubicin; podophyllinic acid; 2-ethylhydrazide; procarbazine; PSKTM; razoxane; sizofuran; spirogermanium; tenuazonic acid; triaziquone; 2,2′,2′′-trichlorotriethylamine; urethan; vindesine; dacarbazine; mannomustine; mitobronitol; mitolactol; pipobroman; gacytosine; arabinoside (“Ara-C”); cyclophosphamide; thiotepa; taxanes, e.g. paclitaxel (TAXOLTM, Bristol-Myers Squibb Oncology, Princeton, N.J.) and docetaxel (TAXOTERETM; Aventis Antony, France); chlorambucil; gemcitabine; 6-thioguanine; mercaptopurine; methotrexate; platinum analogs such as cisplatin and carboplatin; vinblastine; platinum; etoposide (VP-16); ifosfamide; mitomycin C; mitoxantrone; vincristine; vinorelbine; navelbine; novantrone; teniposide; daunomycin; aminopterin; capecitabine; ibandronate; CPT-11; topoisomerase inhibitor RFS 2000; difluoromethylornithine; retinoic acid; esperamicins; capecitabine; and pharmaceutically acceptable salts, acids or derivatives of any of the above. Also included are anti-hormonal agents that act to regulate or inhibit hormone action on tumors such as anti-estrogens including for example tamoxifen, raloxifene, aromatase inhibiting 4(5)-imidazoles, 4-hydroxytamoxifen, trioxifene, keoxifene, LY 117018, onapristone, and toremifene (Fareston); and anti-androgens such as flutamide, nilutamide, bicalutamide, leuprolide, and goserelin; and pharmaceutically acceptable salts, acids or derivatives of any of the above.
“Growth inhibitory agents” are compounds which inhibit growth of cells, especially cancer cells, either in vitro or in vivo. Growth inhibitory agents include but are not limited to: agents that block cell cycle progression, such as vincas (vincristine and vinblastine), TAXOLTM, and topo II inhibitors such as doxorubicin, epirubicin, daunorubicin, etoposide, bleomycin, DNA alkylating agents such as tamoxifen, prednisone, dacarbazine, mechlorethamine, cisplatin, methotrexate, 5-fluorouracil, and ara-C.
“Therapeutic antibodies” include antibodies that are used to specifically target cancer cells. Therapeutic antibodies include but are not limited to: rituximab (Rituxan), cetuximab (Erbitux), ibritumomab (Zevalin), gemtuzumab (Mylotarg), trastuzumab (Herceptin), alemtuzumab (Campath), bevacizumab (Avastin), panitumumab (Vectibix), and tositumomab (Bexxar).
Methods of Administration
In order to control hypertension in subjects having the condition or at risk for it, it can be desirable to co-administer the anti-DLL4 antibody and one or more anti-hypertensive agent. In one embodiment, the use of the anti-DLL4 antibody and one or more anti-hypertensive agent is directed for those subjects having hypertension or at risk for its development.
The pharmaceutical composition of the present invention can be administered in any number of ways for either local or systemic treatment. Administration can be topical (such as to mucous membranes including vaginal and rectal delivery) such as transdermal patches, ointments, lotions, creams, gels, drops, suppositories, sprays, liquids and powders; pulmonary (e.g., by inhalation or insufflation of powders or aerosols, including by nebulizer; intratracheal, intranasal, epidermal and transdermal); oral; or parenteral including intravenous, intraarterial, subcutaneous, intraperitoneal, intraocular or intramuscular injection or infusion; or intracranial (e.g., intrathecal or intraventricular) administration. The pharmaceutical composition of the invention can be administered by any convenient route, such as infusion or bolus injection.
Administration can be acute (i.e., a single administration of the composition) or chronic (i.e., daily, weekly, monthly administration).
Administration of the anti-DLL4 antibody and the anti-hypertensive agent can include co-administration, either in a single pharmaceutical formulation or using separate formulations, or consecutive administration in either order but generally within a time period such that all active agents can exert their biological activities simultaneously. Preparation and dosing schedules for anti-hypertensive agents can be used according to manufacturers' instructions or as determined empirically by the skilled practitioner.
For the treatment of cancer with an anti-DLL4 antibody, the appropriate dosage of the anti-DLL4 antibody can be determined by the treating physician. The size of a tumor, the presence of malignant disease, and the extent of metastasis are factors to be considered when determining a dosage. The anti-DLL4 antibody can be administered one time or over a series of treatments lasting from several days to several months. Preferably, the anti-DLL4 antibody is administered chronically until a cure is effected or a diminution of the disease state is achieved (e.g. reduction in tumor size). Optimal dosing schedules can be calculated from measurements of drug accumulation in the body of the patient and will vary depending on the relative potency of the individual anti-DLL4 antibody. The administering physician can easily determine optimum dosages, dosing methodologies and repetition rates. In general, dosage is from 0.01 μg to 100 mg per kg of body weight, and can be given once or more daily, weekly, monthly or yearly. Repetition rates can be estimated for dosing based on measured residence times and concentrations of the drug in bodily fluids or tissues. The treating physician can monitor the disease state of the patient (i.e., increases or decreases in tumor size, presence or spread of metastasis, appearance of malignancies, quality of life) and adjust the dosage of the anti-DLL4 antibody accordingly.
For treatment of cancer with an anti-DLL4 antibody, such as OMP-21M18, in certain embodiments, suitable dosages for intravenous administration are between about 0.1 mg/kg and about 20 mg/kg. In certain embodiments, dosages of the anti-DLL4 antibody, such as OMP-21M18, are about 0.1 mg/kg; about 0.2 mg/kg; about 0.5 mg/kg; about 1.0 mg/kg; about 2.5 mg/kg; about 5.0 mg/kg; about 7.5 mg/kg; about 10 mg/kg; and about 15 mg/kg. Administration can be daily, twice per week, once per week, once every other week, once every three weeks, monthly, or any other suitable interval at the discretion of the treating physician. Dosages and intervals of administration can be adjusted to optimize treatment efficacy.
For the treatment of hypertension, the appropriate dosage of the anti-hypertensive agent depends on the severity and course of the hypertension, the responsiveness of the subject, whether the anti-hypertensive is administered for therapeutic or preventative purposes, the subject's previous therapy, the subject's clinical history, and so on, at the discretion of the treating physician. The anti-hypertensive agent can be administered one time or over a series of treatments lasting from several days to several months. Preferably, the anti-hypertensive agent is administered chronically until treatment with the anti-DLL4 antibody has ceased. Optimal dosing schedules can be calculated from measurements of drug accumulation in the body of the patient and will vary depending on the relative potency of the individual anti-hypertensive agent. Additionally, effective dosages for anti-hypertensive agents available commercially will be provided by the manufacturer. The administering physician can easily determine optimum dosages, dosing methodologies and repetition rates. In general, dosage is from 0.01 μg to 100 mg per kg of body weight, and can be given once or more daily, weekly, monthly or yearly. The treating physician can estimate repetition rates for dosing based on measured residence times and concentrations of the drug in bodily fluids or tissues. Furthermore, the treating physician can monitor the blood pressure of a subject and adjust the amount of an anti-hypertensive administered, the frequency of dosing, or the particular anti-hypertensive used to suit the needs of the patient. In a human clinical setting non-invasive methods for measuring blood pressure would be used. For example, a simple arm cuff or sphygmomanometer measure blood pressure directly using the oscillometric method or connected to a pulse transducer for continuous measurement. More than one anti-hypertensive medication can be used concurrently to effectively control hypertension in a subject receiving treatment with an anti-DLL4 antibody.
The present invention provides methods of preventing hypertension in a patient receiving treatment with a DLL4 antagonist or an anti-DLL4 antibody comprising administering to the patient an effective amount of one or more anti-hypertensive agents. “Preventing hypertension” means that the patient's blood pressure is kept, on average, below the range considered to be hypertension throughout the course of treatment with the DLL4 antagonist or anti-DLL4 antibody. A blood pressure consistently at or above 140 mmHg systolic or 90 mmHg diastolic is considered hypertension. A blood pressure consistently in the range of 120-139 mmHg systolic or 80-89 diastolic is considered pre-hypertension. Depending on the tolerances of the treating physician, “preventing hypertension” can mean keeping a patient's blood pressure below the range considered hypertension, or keeping a patient's blood pressure below the range considered pre-hypertension.
The present invention provides methods for monitoring a patient receiving treatment with a DLL4 antagonist or an anti-DLL4 antibody for the development of hypertension comprising measuring the blood pressure of the patient receiving treatment with the DLL4 antagonist or anti-DLL4 antibody for a blood pressure elevated above the normal range and administering to the patient with the elevated blood pressure one or more anti-hypertensive agents. The treating physician can measure the patient's blood pressure before, during, and after treatment with the DLL4 antagonist or anti-DLL4 antibody. Blood pressure measurement before treatment can be used to establish a baseline blood pressure. If the baseline blood pressure is in the pre-hypertensive or hypertensive range, the treating physician can opt to begin administration of anti-hypertensive agents immediately, either before or concurrently with the administration of the DLL4 antagonist or anti-DLL4 antibody. Blood pressure monitoring of the patient would continue after initiation of treatment with the DLL4 antagonist or anti-DLL4 antibody to ensure that the anti-hypertensive regimen is adequately controlling the patient's hypertension. If the baseline blood pressure is in the normal range, the treating physician can opt to continue monitoring blood pressure after treatment with the DLL4 antagonist or anti-DLL4 antibody begins and initiating treatment with anti-hypertensives only if the patient's blood pressure rises. Alternatively, the treating physician can decide to prophylactically administer anti-hypertensives to a patient whose baseline blood pressure is in the normal range to pre-empt the development of hypertension after treatment with the DLL4 antagonist or anti-DLL4 antibody begins.
After treatment with the DLL4 antagonist or anti-DLL4 antibody is initiated, routine monitoring of the patient's blood pressure is performed. Blood pressure readings can be taken at any appropriate interval: daily, every other day, bi-weekly, weekly, biweekly, monthly, or at any interval deemed appropriate by the physician. If the blood pressure of a patient becomes elevated into the hypertension range, the treating physician can initiate anti-hypertensive treatment. The dosages, particular anti-hypertensive medications used, and dosing schedule can be adjusted by the physician as necessary to adequately control the patient's hypertension. If the blood pressure of a patient becomes elevated into the pre-hypertension range, the treating physician can initiate anti-hypertensive treatment or continue monitoring the patient and begin anti-hypertensive treatment only if the patient's blood pressure rises into the hypertension range. If the blood pressure of a patient becomes elevated significantly compared to the baseline blood pressure reading, but is not in the pre-hypertension or hypertension range, the treating physician can prophylactically initiate anti-hypertensive treatment to prevent the patient's blood pressure from continuing to rise, or continue monitoring the patient and begin anti-hypertensive treatment only if the patient's blood pressure rises into the pre-hypertension or hypertension range. If a patient is initiated on anti-hypertensive treatment and their blood pressure does not decrease or continues to rise, the treating physician can increase the dosage of the anti-hypertensive, add one or more additional anti-hypertensive medications to the treatment regimen, change the anti-hypertensive medication, or take more than one of the preceding steps in order to reduce the patient's blood pressure to an acceptable level.
Treatment Population
The pharmaceutical compositions and methods of the present invention can be used to treat subjects suffering from cancer. In certain embodiments, the methods of the invention allow the treatment of subjects suffering from cancer with an anti-DLL4 antibody at a dosage that could not otherwise be used without placing certain subjects at risk for developing complications due to hypertension.
In certain embodiments, the subjects are those suffering from hypertension or pre-hypertension prior to the start of therapy with an anti-DLL4 antibody, subjects over the age of 65 years old, subjects with or at risk for developing cardiovascular disease, or subjects who develop hypertension or pre-hypertension after the start of treatment with an anti-DLL4 antibody.
Subjects at risk for developing cardiovascular disease include those over 65 years of age, of the male sex, or who have hereditary factors linked to cardiovascular disease. The risk of cardiovascular disease increases with increasing age. Over 83 percent of people who die of coronary heart disease are 65 or older. Men overall have a higher risk of cardiovascular disease than women, and experience heart attacks earlier in life. Children of parents who had cardiovascular disease are more likely than children of parents who did not have cardiovascular disease to develop cardiovascular disease themselves, suggesting a hereditary link. Additionally, people of certain races are more likely to develop cardiovascular disease than other races. For example, African Americans, Mexican Americans, native Hawaiians, and American Indians have a greater risk of developing cardiovascular disease than Caucasians.
Additionally, lifestyle factors can contribute to a subject's likelihood of developing cardiovascular disease. Smoking, physical inactivity, excessive drinking of alcohol, high levels of stress, and obesity all increase a subject's likelihood of developing cardiovascular disease. Preexisting conditions can also increase a subject's likelihood of developing cardiovascular disease. Diabetes mellitus, high blood cholesterol, high blood pressure, and clogged arteries are all risk factors for cardiovascular disease.
Subjects at risk for developing hypertension include those subjects over 45 years of age, male subjects, or those with hereditary traits linked to hypertension. The risk of hypertension increases with age. Males over 45 years of age and women over 55 years of age are at an increased risk of developing hypertension. Additionally, men overall have a higher risk of hypertension than women.
Subjects whose blood pressure is in the range considered to be “pre-hypertension” are more likely than subjects whose blood pressure is in the normal range to develop hypertension.
The prevention or inhibition of hypertension is desirable in any subject receiving treatment with a DLL4 antagonist or anti-DLL4 antibody. Prevention or treatment of hypertension is particularly desirable in subjects who, prior to the start of treatment with a DLL4 inhibitor or anti-DLL4 antibody suffer from hypertension or pre-hypertension, are at risk for developing cardiovascular disease, are at risk for developing hypertension, or have a condition which would be exacerbated by hypertension, such as heart failure, aneurysms, kidney disease, or narrowed arteries.
In certain embodiments, the subjects to be treated with a Dll4 antagonist do not have a prior history of hypertension. In certain alternative embodiments, the subjects do not have a prior history of cardiovascular disease. Methods of monitoring such subjects for the development of hypertension, optionally followed by the subsequent administration of anti-hypertensives if hypertension does develop, are provided.
Methods of screening patients for treatment with a Dll4 antagonist, such as an anti-Dll4 antibody, are also provided. In certain embodiments, the methods comprise selecting patients based on a lack of prior history of hypertension and/or cardiovascular disease. Thus, in certain methods, the subjects having no prior history of hypertension (and/or cardiovascular disease) are treated with the Dll4 antagonist. In certain alternative embodiments, subjects having a prior history of hypertension and/or cardiovascular disease are selected for treatment with both a Dll4 antagonist and an anti-hypertensive.
The invention is not limited to the treatment of tumors or cancer, and includes other, non-malignant diseases that are characterized by the presence of vascular proliferation. Vascular Proliferation disorders include those of the eye such as Macular Degeneration and Diabetic Retinopathy.
Kits
The invention also provides kits comprising an anti-DLL4 antibody and anti-hypertensive agent and that can be used to perform the methods described herein. In certain embodiments, the kit comprises an anti-DLL4 antibody and a package insert contained within a packaging material. In other embodiments, the kit comprises an anti-DLL4 antibody, at least one anti-hypertensive agent, and a package insert contained within a packaging material. The anti-DLL4 antibody and the one or more anti-hypertensive agents can be admixed together in a single pharmaceutical composition for concomitant administration, or can be in separate containers for sequential or concomitant administration. In other embodiments, the kit can also comprise one or more additional anti-cancer therapeutic agents, such as a chemotherapeutic or a therapeutic antibody. In certain embodiments, the package insert will indicate that the anti-DLL4 antibody can be used for treating cancer or reducing tumor growth, that the anti-hypertensive agent can be used in combination with the anti-DLL4 antibody to reduce hypertension caused by the administration of the anti-DLL4 antibody, or contain instructions on the dosage, administration schedule, and monitoring of subjects undergoing treatment with the anti-DLL4 antibody and anti-hypertensive agent. One skilled in the art will readily recognize that the disclosed pharmaceutical compositions of the present invention can be readily incorporated into one of the established kit formats which are well known in the art.
Embodiments of the present disclosure can be further defined by reference to the following examples. It will be apparent to those skilled in the art that many modifications, both to materials and methods, can be practiced without departing from the scope of the present disclosure. As used herein and in the appended claims, the singular forms “a,” “or,” and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to “an anti-hypertensive agent” includes a plurality of such agents or equivalents thereof known to those skilled in the art. Furthermore, all numbers expressing quantities of ingredients, dosage amounts, blood pressure readings, and so forth, used in the specification, are modified by the term “about,” unless otherwise indicated. Accordingly, the numerical parameters set forth in the specification and claims are approximations that can vary depending upon the desired properties of the present invention.
EXAMPLES
Example 1
Phase 1 Dose Escalation Study of OMP-21M18 in Subjects with Solid Tumors
Thirty-three subjects with advanced solid tumors initiated treatment with OMP-21M18 in a Phase I clinical trial. The trial was designed to determine the maximum tolerated dose (MTD), safety, pharmacokinetics, immunogenicity, and preliminary efficacy of OMP-21M18 in subjects with advanced solid tumors. All subjects had histologically confirmed malignancies that were metastatic or unresectable and had received extensive treatment for their cancer. At the time of enrollment, there was no remaining standard curative therapy and no therapy with a demonstrated survival benefit.
OMP-21M18 was prepared for use at a concentration of 10 mg/mL in a solution of 50 mM histidine, 100 mM sodium chloride, 45 mM sucrose, and 0.01% (w/v) Polysorbate 20, with the pH adjusted to 6.0. Once prepared, OMP-21M18 was stored as 20 mL aliquots in 25-cc vials.
OMP-21M18 was administered at dosages of 0.5 mg/kg weekly to three subjects, 1.0 mg/kg weekly to three subjects, 2.5 mg/kg every two weeks to six subjects, 2.5 mg/kg weekly to six subjects, 5.0 mg/kg every two weeks to six subjects, 5.0 mg/kg weekly to three subjects, and 10.0 mg/kg every two weeks to six subjects. According to the study protocol, the administration period was nine weeks, unless a subject was removed from the study due to a dose limiting toxicity. Baseline blood pressure readings were taken just prior to administration of the first dosage. Toxicities were assessed using the National Institute of Health's Common Toxicity Criteria for Adverse Events (CTCAE) version 3.0. During the study, subjects were assessed for dose limiting toxicities from the time of the first dose through 7 days after administration of the fourth dose (Days 0-28). Subjects who experienced a dose limiting toxicity had their treatment with OMP-21M18 permanently discontinued. After nine weeks of treatment, if a subject continued to receive treatment and had no evidence of disease progression or if their tumor was smaller, the subject was allowed to continue to receive IV infusions of OMP-21M18 every other week until disease progression.
Twenty-two of the subjects treated in the trial had a prior diagnosis of hypertension. Of these subjects, 8 were taking a single medication and 1 subject each were taking two or three medications.
During the course of therapy, hypertension was reported for twelve of the thirty-three subjects, or 36% of patients treated with OMP-21M18. In eleven of these subjects, the hypertension was labeled “grade three” because an oral anti-hypertensive medication was administered and adjusted to successfully control the subject's blood pressure. In these eleven cases, the hypertension was asymptomatic and subjects were able to continue treatment with OMP-21M18.
There appears to be a dose relationship to hypertension. Hypertension has been observed across the full range of doses, with the greatest incidence at the highest dose administered. At the 10.0 mg/kg dose level, 6 of 6 subjects experienced Grade 3 hypertension (severe) or Grade 4 hypertension (life threatening).







TABLE 1







Incidence of Hypertension in Dosage Cohorts















Grade 3
Grade 4



Dosage

Number of
Hyper-
Hyper-
Total Incidence


(mg/kg)
Schedule
Patients
tension
tension
of Hypertension















0.5
weekly
3
1
0
1/3


1.0
weekly
3
1
0
1/3


2.5
every 2
6
1
0
1/6



weeks


2.5
weekly
6
2
0
2/6


5.0
every 2
6
1
0
1/3



weeks


5.0
weekly
3
0
0
0/3


10.0
every 2
 61
6
1
6/6



weeks





1one patient experienced both Grade 3 and Grade 4 hypertension






Example 2
Hypertension and Treatment in Subject No. 1
Subject 1, enrolled in the 0.5 mg/kg cohort, is a 78-year-old male with adenocarcinoma of the caecum with metastases to the liver. The Table of FIGS. 1A-B is a summary of Subject 1's blood pressure readings and anti-hypertensive treatments throughout the Phase I study of OMP-21M18. The subject's past medical history includes a diagnosis of hypertension, myocardial infarction (15 years prior), congestive heart failure, and paroxysmal atrial fibrillation. At study entry, the subject had been taking benazepril hydrochloride (Lotensin®) 30 mg po qd for hypertension for the past five months. On Day 1, the subject's baseline blood pressure was 135/73 mm Hg, On Day 0, the subject received his first weekly dose of OMP-21M18 at 0.5 mg/kg. Due to an increase in blood pressure to 183/89 on Day 24, his Lotensin® dose was increased to 40 mg po qd and amlodipine besylate (Norvasc®) 5 mg/qd was started. The Norvasc® dose was increased to 10 mg po qd on Day 32 due a blood pressure reading of 177/88 mm Hg. On Day 41, hydrochlorothiazide was added due to a blood pressure reading of 160/85 mm Hg. The highest blood pressure reported for subject 1 was on Day 21, 15 minutes post infusion, at 199/92. The subject continued on Lotensin®, Norvasc® and hydrochlorothiazide with adequate blood pressure control and no symptoms related to hypertension.
Example 3
Hypertension and Treatment in Subject No. 2
Subject 2, enrolled in the 1.0 mg/kg cohort, is a 55-year-old male with low-grade leiomyosarcoma. The Table of FIGS. 2A-2C is a summary of Subject 2's blood pressure readings and anti-hypertensive treatments throughout the Phase I study of OMP-21M18. The subject's prior medical history included a diagnosis of hypertension. At study entry, the subject had been taking lisinopril 10 mg po qd for over three years for hypertension. Baseline blood pressure was 141/85 mm Hg. On Day 0, the subject received his first weekly dose of OMP-21M18 at 1 mg/kg. On Day 7, the subject's blood pressure increased to a high of 177/93 mm Hg, and thus on Day 13 irbesartsan/hydrochlorothiazide 300/12.5 mg po qd was added to the lisinopril. On Day 14, the scheduled dose of study drug was not administered due to a hypertensive blood pressure reading of 173/110 mm Hg. The regimen of lisinopril 10 mg po qd plus irbesartsan/hydrochlorothiazide 300/12.5 mg po qd did not adequately control the subject's blood pressure, and thus on Day 17, the irbesartan/hydrochiorothiazide and lisinopril were discontinued and labetalol 100 mg po bid and Prinzide® 10/12.5 po qd were initiated. On Day 21, the labetalol was increased to 300 mg q am and 200 mg q pm due to a blood pressure reading of 164/112 mm Hg. Two days later, the labatolol dose was increased to 400 mg po bid. This regimen controlled the subject's blood pressure until Day 55, when a blood pressure reading of 163/91 mm Hg was observed that resulted in increasing the Prinzide® dose to 20/25 po qd. On Day 84, the subject's blood pressure was 167/102 mm Hg and lasix 20 mg po qd was added to the regimen. Due to the high blood pressure reading on Day 84, the subject's dose of OMP-21M18 was not administered. On Day 87, to regain blood pressure control, Norvasc® 10 mg po qd was started. The subject's regimen of labetalol 400 po bid, lasix 20 mg po qd, Norvasc® 10 mg po qd, and Prinzide® 20/25 mg po bid, subsequently controlled his blood pressure, allowing him to receive 7 additional doses of OMP-21M18 without hypertension.
Example 4
Hypertension and Treatment in Subject No. 3
Subject 3, enrolled in the 2.5 mg/kg cohort, is a 64-year-old woman with a choroidal melanoma of the right eye and metastases in both the liver and the lung. The Table of FIG. 3 is a summary of Subject 3's blood pressure readings and anti-hypertensive treatments throughout the Phase I study of OMP-21M18. This subject had no prior history of hypertension. The subject's baseline blood pressure was 96/54 mm Hg. On Day 0, the subject received her first weekly dose of OMP-21M18 at 2.5 mg/kg. On Day 21, the subject had a blood pressure reading of 159/90 mmHg and was started on Dyazide® (hydrochlorothiazide and triamterene) 1 po qd. The subject's blood pressure was adequately controlled until Day 112, when her blood pressure was noted to be elevated to 152/77 mm Hg. To regain blood pressure control, Dyazide® was discontinued and the subject was begun on Norvasc® (amlodipine besylate) 5 mg po qd. On Day 141, Norvasc® treatment was discontinued due to ankle edema and lisinopril 20 mg po qd was begun. On Day 144, the subject's lisinopril dose was increased to 20 mg po bid. On Day 146 the subject's blood pressure reading was 143/85 mm Hg. The subject has not had symptoms related to the blood pressure increase. The subject remained on treatment and received 13 infusions of OMP-21M18.
Example 5
Hypertension and Treatment in Subject No. 4
Subject 4, enrolled in the 2.5 mg/kg cohort, had a history of hypertension and was taking dyazide and lisinopril at study entry. The subject's blood pressure at baseline was 118/73. On Day 14, the subject had a blood pressure of 153/79. The increase in blood pressure was not related to the study drug according to the Investigator. The subject did not have symptoms related to the hypertension.
Example 6
Hypertension and Treatment in Subject No. 5
Subject 5, enrolled in the 10 mg/kg cohort, is a 56-year-old female with stage IV colorectal cancer. The Table of FIG. 4 is a summary of Subject 5's blood pressure readings and anti-hypertensive treatments throughout the Phase I study of OMP-21M18. The subject's past medical history includes diagnoses of coronary heart disease, atherosclerosis, and exertional angina (class 1). Subject 5's baseline blood pressure was 130/90 mm Hg on Day −28. On Day 0, the subject received her first dose of once every other week OMP-21M18 at 10 mg/kg. On Day 9, the subject's blood pressure was high, at 160/90 mm Hg, and she was started on lisinopril 10 mg po qd. On Day 14, the subject's blood pressure readings in the clinic were lower, at 135-140/90 mm Hg, and therefore her dose of lisinopril was reduced to 5 mg po qd. On Day 26, the subject's blood pressure at home was 170/90 mm Hg and was treated with a single dose of captopril 25 mg po. On Day 28, the subject's dosage of lisinopril was increased back to 10 mg po qd. On Day 56, the dose of lisinopril was increased to 10 mg po bid due to blood pressure readings of 140-145/90 mm Hg. On Day 62, the subject had a blood pressure of 190/120 mm Jig and was seen by a cardiologist who discontinued the lisinopril and started her on lozartan 25 mg po qd, bisoprolol 2.5 mg po qd and amlodipine 5 mg po qd. Three days later, on Day 65, the subject's blood pressure was still 170/106 mm Hg. The cardiologist increased the dose of lozartan to 50 mg po qd and increased the dose of bisoprolol to 5 mg po qd.
Example 7
Hypertension and Treatment in Subject No. 6
Subject 6, enrolled in the 10 mg/kg cohort, did not have a prior history of hypertension. The subject's baseline blood pressure was 125/90. On Day 9, the subject was started on enalapril 10 mg bid. The subsequent blood pressure was 140/90. On Day 28 the subject had a single blood pressure reading of 150/90. A subsequent blood pressure reading was 150/90. The subject did not have symptoms related to hypertension and continued to receive treatment.
Example 8
Hypertension and Treatment in Subject No. 7
Subject 7, enrolled in the 10 mg/kg cohort, is a 71-year-old female with stage IV adenocarcinoma of the rectosigmoid junction. The Table of FIG. 5 is a summary of Subject 7's blood pressure readings and anti-hypertensive treatments throughout the Phase I study of OMP-21M18. The subject's past medical history includes diagnoses of coronary heart disease, arterial hypertension, and atherosclerosis. The subject has been taking enalapril 5 mg po bid for hypertension for the past 10 years. On Day −1, the subject's baseline blood pressure was 135/90 mm Hg. On Day 0, she received her first dose of once every other week OMP-21M18 at 10 mg/kg. On Day 9, the subject's enalapril dose was increased to 10 mg bid when the subject's blood pressure reading was 170/90 mm Hg. On Day 56, amlodipine 5 mg po qd was started when the subject's blood pressure reading was 155/90 mm Hg. The subject's blood pressure readings on Day 70 were 145-150/90 mm Hg. The subject did not have symptoms related to hypertension and continued to receive treatment.
Example 9
Hypertension and Treatment in Subject No. 8
Subject 8, enrolled in the 10 mg/kg cohort, is a 58-year-old man with stage IV colorectal cancer. The Table of FIG. 6 is a summary of Subject 8's blood pressure readings and anti-hypertensive treatments throughout the Phase I study of OMP-21M18. His past medical history includes a diagnosis hypertension. At the time of study entry, the subject had been taking captopril 25 mg po qd as needed for the past 6 years to control his blood pressure. The subject's baseline blood pressure on Day −28 was 140/90 mm Hg. On Day 0, he received his first dose of once every other week OMP-21M18 10 mg/kg. On Day 18, the subject's captopril dose was changed to 12.5 po qd due to a home blood pressure reading of 160/90 mm Hg on Day 17. The subject's next blood pressure in the clinic on Day 22 was 130/80 mm Hg. On Days 23-28, the subjects blood pressure at home measured 150/90 mm Hg and thus the subject's captopril dose was increased to 25 mg po qd. Subsequently, the subject received 5 additional doses of OMP-21M18 without any further adjustments of his blood pressure medications. The subject did not had symptoms related to the reported hypertension and remained on treatment.
Example 10
Hypertension and Treatment in Subject No. 9
Subject 9, enrolled in the 10 mg/kg cohort, is a 54-year-old man with locally advanced adenocarcinoma of the head of the pancreas. The Table of FIG. 7 is a summary of Subject 9's blood pressure readings and anti-hypertensive treatments throughout the Phase I study of OMP-21M18. The subject received prior treatment with gemcitabine. The subject did not have a history of hypertension. The subject's blood pressure on Day −1 was 115/75 mm Hg. On Day 0, he received his first dose of once every other week OMP-21M18 10 mg/kg. On Day 3, the subject reported an increased blood pressure of 140-145/90-95 mm Hg and was started on nifedipine 20 mg po qd. The subject's next blood pressure reading on Day 7 was 130/80 mm Hg. On Day 74, the nifedipine was discontinued by the subject due to normalization of his blood pressure (115/75 mm Hg). The subject has not had symptoms related to hypertension and remains on treatment at Day 81.

## Claims

1. A method of treating cancer comprising: administering to a human subject in need thereof a delta like ligand-4 (DLL4) antagonist, wherein the DLL4 antagonist is an antibody that specifically binds human DLL4, and further administering a therapeutically effective amount of one or more anti-hypertensive agents to the human subject to control hypertension caused by the antibody.

2. The method of claim 1, wherein the human subject suffers from hypertension, is at risk for development of hypertension, or is a human subject in which the prevention or inhibition of hypertension is desirable.

3. The method of claim 1, wherein the human subject is at risk for cardiovascular disease or cannot otherwise be treated with an appropriate dose of the DLL4 antagonist without developing hypertension.

4. The method of claim 1, wherein the antibody and the anti-hypertensive agent are administered separately or simultaneously.

5. The method of claim 1, wherein the antibody is encoded by the plasmid having ATCC deposit no. PTA-8425.

6. The method of claim 1, wherein the antibody competes for specific binding to human DLL4 with an antibody encoded by the plasmid deposited with ATCC, having deposit no. PTA-8425.

7. The method of claim 1, wherein the antibody is selected from the group consisting of: monoclonal, humanized, chimeric, human, Fab, Fv and scFv.

8. The method of claim 7, wherein the antibody is a monoclonal antibody.

9. The method of claim 1, wherein the antibody comprises: (i) a heavy chain variable region comprising CDR amino acid sequences CDR1 (SEQ ID NO:1); CDR2 (SEQ ID NO:2, SEQ ID NO:3, or SEQ ID NO:4); and CDR3 (SEQ ID NO:5), and (ii) a light chain variable region comprising CDR amino acid sequences CDR1 (SEQ ID NO:7); CDR2 (SEQ ID NO:8); and CDR3 (SEQ ID NO:9).

10. The method of claim 9, wherein the heavy chain variable region comprises CDR amino acid sequences CDR1 (SEQ ID NO:1), CDR2 (SEQ ID NO:3), and CDR3 (SEQ ID NO:5), and the light chain variable region comprises CDR amino acid sequences CDR1 (SEQ ID NO:7); CDR2 (SEQ ID NO:8); and CDR3 (SEQ ID NO:9).

11. The method of claim 1, wherein the antibody comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO:6.

12. The method of claim 1, wherein the antibody comprises a light chain variable region comprising the amino acid sequence of SEQ ID NO:10.

13. The method of claim 1, wherein the anti-hypertensive agent is selected from the group consisting of a diuretic, an adrenergic receptor antagonist, an adrenergic receptor agonist, a calcium channel blocker, an ACE inhibitor, an angiotensin II receptor antagonist, an aldosterone antagonist, a vasodilator, a renin inhibitor, and combinations thereof.

14. The method of claim 13, wherein the anti-hypertensive agent is a diuretic selected from the group, consisting of: furosemide, bumetanide, ethacrynic acid, torsemide, epitizide, hydrochlorothiazide, hydroflumethiazide, chlorothiazide bendroflumethiazide, polythiazide, trichlormethiazide cyclopenthiazide, methyclothiazide, cyclothiazide, mebutizide, indapamide, chlortalidone, metolazone, quinethazone, clopamide, mefruside, clofenamide, meticrane, xipamide, clorexolone, fenquizone, amiloride, triamterene, eplerenone, benzamil, potassium canrenoate, canrenone, spironolactone mannitol, glucose, urea, conivaptan, relcovaptan, nelivaptan, lixivaptan, mozavaptan, satavaptan, tolvaptan, demeclocycline, mersalyl acid, meralluride, mercaptomerin, mercurophyllme, merethoxyllme procaine, calomel, caffeine, theobromine, paraxanthine, theophylline, acetazolamide, methazolamide, dorzolamide, sulfonamide, topiramate, amanozine, arbutin, chlorazanil etozolin, hydracarbazine, isosorbide, metochalcone, muzohmme, perhexiline, and ticrynafen.

15. The method of claim 13, wherein the anti-hypertensive agent is an adrenergic receptor antagonist selected from the group consisting of: atenolol, metoprolol, nadolol oxprenolol, pindolol, propranolol, timolol, acebutolol, bisoprolol, esmolol, labetalol, carvedilol, bucindolol, nebivolol, amosulalol, arotinolol, befunolol, betaxolol, bevantolot, bopindolol, bucumolol, bufetolol, bufuralol, bumtrolol, bupranolol, butidrine hydrochloride, butofilolol, carazolol, carteolol, celiprolol, cetamolol, cloranololdilevalol, epanolol, indenolol, levobunolol, mepindolol, metipranolol, moprolol, nadoxolol, nipradilol, penbutolol, practolol, pronethalol, sotalol, sulfmalol, talinolol, tertatolol, tilisolol, toliprolol, xibenolol, phenoxybenzamine, prazosin, doxazosin, terazosin, trimazosin, phentolamine, amosulalol, arotinolol, dapiprazole, fenspinde, indoramin, labetalol, naftopidil, nicergolme, tamsulosin, tolazolme, moxonidine, reserpine, and yohimbine.

16. The method of claim 13, wherein the anti-hypertensive agent is an adrenergic receptor agonist selected from the group consisting of: clonidine, methyldopa, guanfacine, methoxamine, methylnorepinephrine, oxymetazoline, phenylephrine, guanabenz, guanoxabenz, guanethidine, xylazine, and tizanidme.

17. The method of claim 13, wherein the anti-hypertensive agent is a calcium channel blocker selected from the group consisting of: amlodipine, felodipine, nicardipine, nifedipine, nimodipine, isradipine, nitrendipine, aranidipine, barnidipine, benidipine, cilnidipine, efonidipine, elgodipine, lacidipine, lercanidipine, manidipine, nilvadipine, nisoldipine, diltiazem, verapamil, bepridil, clentiazem, fendiline, gallopamil, mibefradil, prenylamine, semotiadil, terodiline, cinnarizine, flunarizine, lidoflazine, lomerizine, bencyclane, etafenone, and perhexiline.

18. The method of claim 13, wherein the anti-hypertensive agent is an ACE inhibitor.

19. The method of claim 18, wherein the ACE inhibitor is selected from the group consisting of: captopril, zofenopril, enalapril, ramipril, quinapril, perindopril, lismopril, benazepril, fosinopril, ceronapril, casokinins, lactokinins, teprotide, alacepril, cilazapril, delapril, imidapnl, moexipnl, rentiapril, spirapril, temocapril, moveltipnl and trandolapril.

20. The method of claim 13, wherein the anti-hypertensive agent is an angiotensin II receptor antagonist selected from the group consisting of: candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, and valsartan.

21. The method of claim 13, wherein the anti-hypertensive agent is an aldosterone antagonist selected from the group consisting of: eplerenone, canrenone, and spironolactone.

22. The method of claim 13, wherein the anti-hypertensive agent is a vasodilator selected from the group consisting of: bencyclane, cinnarizine, citicoline, cyclandelate, ciclonicate, diisopropylamine dichloroacetate, eburnamonine, fasudil, fenoxedil, flunarizine, ibudilast, ifenprodil, lomerizine, nafronyl, nicametate, nicergoline, nimodipine, papaverine, tinofedrine, vincamine, vinpocetine, viquidil, amotriphene, bendazol, benfurodil hemisuccinate, benziodarone, chloracizme, chromonar, clobenfural, clonitrate, cloricromen, dilazep, dipyridamole, droprenilamine, efloxate, erythrityl tetranitrate, etafenone, fendiline, floredil, ganglefene, hexestrol bis(P-diethylaminoethyl) ether, hexobendine, itramin tosylate, khellin, lidoflazine, mannitol hexanitrate, medibazine, nitroglycerin, pentaerythritol tetranitrate, pentrinitrol, perhexiline, pimefylline, prenylamine, propatyl nitrate, trapidil, tricromyl, trimetazidine, trolnitrate phosphate, sildenafil, tadalafil, vardenafil, sodium nitroprusside, isosorbide mononitrate, isosorbide dinitrate, pentaerythritol, tetranitrate, theobromine, visnadine, aluminum nicotinate, bamethan, bencyclane, betahistine, brandykinin, brovincamine, bufeniode, buflomedil, butalamine, cetiedil, ciclonicate, cinepazide, cinnarizine, cyclandelate, diisopropylamine dichloroacetate, eledoisin, fenoxedil, flunarizine, hepronicate, ifenprodil, iloprost, inositol niacinate, isoxsuprine, kallidin, kallikrein, moxisylyte, nafronyl, nicametate, nicergoline, nicofuranose, nylidrin, pentifyllme, pentoxifylline, piribedil, prostaglandin E1, suloctidil, tolazoline, and xanthinol niacinate.

23. The method of claim 13, wherein the anti-hypertensive agent is a renin inhibitor selected from the group consisting of: aliskiren and remikiren.

24. The method, of claim 13, further comprising administering a third therapeutic agent.

25. The method of claim wherein the antibody is an antigen-binding antibody fragment.

26. The method of claim 1, wherein the antibody is a bispecific antibody.

27. A method of ameliorating hypertension in a human patient receiving treatment with a delta like ligand-4 (DLL4) antagonist, wherein the DLL4 antagonist is an antibody that specifically binds human DLL4, said method comprising: administering to the human patient receiving treatment with the antibody, a therapeutically effective amount of one or more anti-hypertensive agents to control hypertension caused by the antibody.

28. The method of claim 27, wherein the antibody and the anti-hypertensive agent are administered separately or simultaneously.

29. The method of claim 27, wherein the anti-hypertensive agent is selected from the group consist of: a diuretic, an adrenergic receptor antagonist, an adrenergic receptor agonist, a calcium channel blocker, an ACE inhibitor, an angiotensin II receptor antagonist, an aldosterone antagonist, a vasodilator, a renin inhibitor, and combinations thereof.

30. The method of claim 27, wherein the antibody is encoded by the plasmid having ATCC deposit no. PTA-8425.

31. The method of claim 27, herein the antibody comprises: (i) a heavy chain variable region comprising CD R amino acid sequences CDR1 (SEQ ID NO:1); CDR2 (SEQ ID NO:2, SEQ ID NO:3, or SEQ ID NO:4); and CDR3 (SEQ ID NO:5), and (ii) a light chain variable region comprising CDR amino acid sequences CDR1 SEQ ID NO:7); CDR2 (SEQ ID NO:8); and CDR3 (SEQ ID NO:9).

32. The method of claim 27, wherein the antibody competes for specific binding to human DLL4 with an antibody encoded by the plasmid deposited with ATCC, having deposit no. PTA-8425.

33. A method of reducing hypertension in a patient receiving treatment with a delta like ligand-4 (DLL4) antagonist, wherein the DLL4 antagonist is an antibody that specifically binds human DLL4, comprising: administering to the patient receiving treatment with the antibody a therapeutically effective amount of one or more anti-hypertensive agents to control hypertension caused by the antibody.

34. The method of claim 33, wherein the anti-hypertensive agent is administered before, concurrently with, or after the administration of the antibody.

35. The method of claim 33 wherein the anti-hypertensive, agent is selected from the group consisting of: a diuretic, an adrenergic receptor antagonist, an adrenergic receptor agonist, a calcium channel blocker, an ACE inhibitor, an angiotensin II receptor antagonist, an aldosterone antagonist, a vasodilator, a renin inhibitor, and combinations thereof.

36. The method of claim 33, wherein the antibody is encoded by the plasmid having ATCC deposit no. PTA-8425.

37. The method of claim 33, wherein the antibody comprises: (i) a heavy chain variable region comprising CDR acid sequences CDR1 (SEQ ID NO:1); CDR2 (SEQ ID NO:2, SEQ ID NO:3, or SEQ ID NO:4); and CDR3 (SEQ ID NO:5), and (ii) a light chain variable region comprising CDR amino acid sequences CDR1 (SEQ ID NO:7); CDR2 (SEQ ID NO:8); and CDR3 (SEQ ID NO:9).

38. The method of claim 33, wherein the anti body competes for specific binding to human DLL4 with an antibody encoded by the plasmid deposited with ATCC, having deposit no. PTA-8425.