# Patent

## Title
Procoagulant molecular decoy for treating hemophilia A or B with or without inhibitor

## Abstract

The present invention relates to a pharmaceutical composition including a modified factor Xa (GDXa), said modified GDXa being nonthrombogenic, able to bind to TFPI but not able to bind to phospholipids, for preventing or treating a hemorrhagic accident in a patient with hemophilia A or B with or without inhibitor.

## Background
The present invention relates to a pharmaceutical composition for preventing or treating a hemorrhagic accident in a patient with hemophilia A or B by means of a modified factor X.
Hemophilia A, like hemophilia B, includes two types of hemophilia, constitutional hemophilia and acquired hemophilia.
Type A constitutional hemophilia is a hemorrhagic disease characterized by a quantitative or qualitative deficiency of FVIII resulting from an abnormality of the FVIII gene. Type B constitutional hemophilia is also a hemorrhagic disease but is characterized by a quantitative or qualitative deficiency of FIX resulting from an abnormality of the FIX gene.
Acquired hemophilia of type A or B is defined by the appearance of autoantibodies directed against said FVIII or FIX.
Hemophilia is reflected in a deficiency of blood coagulation in response to a hemorrhage. Untreated type A or B hemophiliacs have symptoms such as excessive bleeding if injured and sometimes even spontaneous hemorrhages.
The biological activity of factors VIII or IX is evaluated as a percentage of the normal level. A normal individual is considered to have 100% activity. If the activity is undetectable (below 1%), it is severe hemophilia, if the activity is between 1 and 5% the hemophilia is said to be moderate; above that and up to 30% it is minor hemophilia.
Patients with hemophilia A and B can be treated with concentrates comprising FVIII or FIX respectively, which can be plasma derivatives or products resulting from genetic engineering. These concentrates can be administered on the occasion of each hemorrhage, and in this case it is advisable to commence treatment as quickly as possible, on appearance of the first signs. The treatment can also be administered prophylactically, regularly 2 to 3 times per week so as to prevent hemorrhages. However, the treatment can give rise to the appearance of antibodies directed against FVIII or FIX called inhibitors. The presence of said antibodies then makes the administrations of factors VIII or IX ineffective. These antibodies are class G immunoglobulins, predominantly IgG4. They develop soon after the first administrations, often before the tenth. Some patients remain poor responders (antibody titer<10 BU), others called strong responders reach titers that mean they can no longer be treated with the corresponding factor.
At the date of the present invention, no treatment exists that can satisfactorily prevent and/or treat the existence of a hemorrhagic risk in patients with hemophilia A or B who have an inhibitor. In fact, the available products may be ineffective (Astermark J, Donfield S M, DiMichele D M, Gringeri A, Gilbert S A, Waters J, Berntorp E, for the FSG. A randomized comparison of bypassing agents in hemophilia complicated by an inhibitor: the FEIBA NovoSeven Comparative (FENOC) Study. Blood. 2007; 109: 546-51) or their administration may be complicated by thrombotic events (Aledort L M. Comparative thrombotic event incidence after infusion of recombinant factor VIIa versus factor VIII inhibitor bypass activity. J Thromb Haemost. 2004; 2: 1709.).
There is therefore a known need for therapeutic alternatives to the existing treatments. However, development of such a treatment has proved very difficult, as it must:

    
    
        be able to stop the hemorrhage,
        not cause thrombosis,
        permit treatment or prevention of hemorrhagic accidents even in the presence of anti-FVIII or FIX antibodies.
    
    


The present invention answers this need; it relates to a pharmaceutical composition comprising a modified activated factor X (FXa), said modified FXa (GDXa) being nonthrombogenic and able to bind to the tissue factor pathway inhibitor (TFPI) but not possessing a phospholipid binding site—for preventing or treating a hemorrhagic accident in a patient with hemophilia A or B.
The composition according to the invention can also be used for preventing or treating a hemorrhagic accident in hemophiliacs presenting anti-factor VIII (FVIII) or factor IX (FIX) antibodies. The antibodies appeared either following treatment with factors FVIII or FIX or spontaneously such as in acquired hemophilia.
The present invention also relates to the use of a pharmaceutical composition comprising a modified factor Xa (GDXa) for preparing a medicinal product intended for preventing or treating a hemorrhagic accident in a patient with hemophilia A or B, said patient having or not having anti-FVIII or FIX antibodies.
The present invention also relates to a method of preventive treatment of a hemorrhagic syndrome in a patient with hemophilia A or B by administering a modified factor Xa (GDXa).
The present invention also relates to a method of treatment of a hemorrhagic accident in a patient with hemophilia A or B by administering a modified factor Xa (GDXa).
In the context of the present invention, mention of factor FXa refers to the activated factor X obtained by activation of the native factor X naturally present in the plasma or in the isolated state in its original, unmodified form. This term includes the FXs isolated from the plasma but also the FXs produced recombinantly or obtained by chemical synthesis that have been activated. Factor Xa or native factor Xa (FXa) refers, in the context of the present invention, to a protein of the serine protease type involved in coagulation and which is produced in an inactive form, factor X (FX).
Activation of the clotting factor X is a key step in blood coagulation and stopping of hemorrhages. Its activation is necessary for the steps of propagation and amplification of coagulation. Its activation is also necessary for stopping the activation of coagulation through its interaction with TFPI.
FX is activated either by activated factor IX and its cofactor, activated factor VIII, or by the activated factor VII and its cofactor, the tissue factor (TF). FXa forms the complex prothrombinase, which is bound to the membranes with the activated factor V and is the active component in the complex prothrombinase, which catalyzes the conversion of prothrombin to thrombin. In its turn, thrombin catalyzes the conversion of fibrinogen to fibrin, which leads to the formation of clots in the blood and stoppage of bleeding. The activity of FXa can be called “procoagulant activity”.
Leytus et al. (Biochemistry, 1986, 25: 5098-5102) and Venkateswarlu et al. (Biophysical Journal, 2002, 82: 1190-1206) describe factor X and the various domains present in this polypeptide. Catalytic cleavage of the heavy chain permits activation of FX to FXa. FXa comprises a light chain, an example of which is represented by the sequence identifier SEQ ID No. 1 and a heavy chain, an example of which is represented by the sequence identifier SEQ ID No. 2.
In the context of the present invention, the term modified FXa denotes FXa that can no longer bind to phospholipids, no longer possessing procoagulant activity or a reduced procoagulant activity. In the context of the present invention, such a factor is called GDXa. “Procoagulant activity” is defined as the capacity of a factor to cause blood coagulation or the formation of clots. A reduced procoagulant activity signifies that the activity is reduced by at least 50%, preferably at least 90% and even more preferably by more than 95% relative to the activity of the native FXa.
The modified factor Xa according to the invention, GDXa, lacks its γ-carboxyglumatic acid (Gla) domain for binding to phospholipids. The first 43 amino acids of the light chain (residues 1-43 of SEQ ID No. 1) represent the Gla domain as it contains 11 post-translationally modified residues (γ-carboxyglutamic acid). Digestion with chymotrypsin makes it possible to suppress the residues 1-43, making it possible to generate an FXa lacking its domain for binding to phospholipids or GDXa (for Gla Domainless FXa). Said GDXa can also comprise other modifications in addition to absence of its Gla domain. Said modified FXa conserves properties of binding to factor Va but does not possess procoagulant activity. An example of GDXa is represented by the sequence identifier SEQ ID No. 7 or by SEQ ID No. 3 for its light chain and by SEQ ID No. 2 for its heavy chain. This absence of procoagulant activity can be defined by its inability to activate coagulation when it is added to plasma in the absence of tissue factor, which differentiates it from native factor Xa.
GDXa can be obtained by cleavage of factor X by proteolysis controlled by chymotrypsin and activation by a specific protease according to one of the usual methods such as that described by Skogen et al. (1984). An example of GDX prior to its activation can be represented by the sequence identifier SEQ ID No. 20 for its nucleotide sequence and SEQ ID No. 28 for its amino acid sequence.
GDXa can be produced by chemical synthesis, either in the form of a single sequence, or in the form of several sequences which are then joined together. This synthesis can be carried out in the solid phase or in solution. These techniques are more particularly described by Atherton and Shepard in “Solid phase peptide synthesis” (IRL Press Oxford, 1989) and by Houbenweyl (in “Methoden der organischen Chemie” [Methods in Organic Chemistry] published by E. Wunsch Vol. 15-1 and 11, Stuttgart, 1974), as well as in the following articles: P. E. Dawson et al. (Science 1994; 266(5186), pp 776-779); G G Kochendoerfer et al. (1999; 3(6), pp 665-671); P E Dawson et al. (2000, 69, Annu. Rev. Biochem., pp 923-960).
GDXa is nonthrombogenic; its absence of procoagulant activity can be defined by an assay measuring thrombin generation (Hemker et al., Thrombosis and Haemostasis. 1993; 70: 617-624, cf. example 4).
GDXa's capacity for binding to TFPI is defined using any assay well known by a person skilled in the art. Such an assay is described in example 1, employing a chromogenic substrate allowing the percentage inhibition of FXa and GDXa by TFPI to be determined.
In another aspect of the invention GDXa lacks its Gla domain but also the domain EGF1 (Epidermal Growth Factor 1). Such an application of the invention can be represented by a composition comprising a GDXa represented by SEQ ID No. 4 for its light chain and by SEQ ID No. 2 for its heavy chain.
In another aspect of the invention GDXa lacks its Gla domain but also the domain EGF2 (Epidermal Growth Factor 2); an example of such a GDXa is represented by the sequence identifier SEQ ID No. 5 for its light chain and by SEQ ID No. 2 for its heavy chain.
In another aspect of the invention GDXa lacks its domain Gla but also the domains EGF1 and EGF2; an example of such a GDXa is represented by the sequence identifier SEQ ID No. 6 for its light chain and by SEQ ID No. 2 for its heavy chain.
According to another aspect of the invention, GDXa consists solely of the heavy chain of FXa. According to a particular embodiment of the invention, such an FXa is represented by the sequence identifier SEQ ID No. 2.
In yet another different aspect, GDXa consists of molecular variants with mutations. Thus, various mutations were introduced into the gene coding for GDXa enabling thrombin generating activity to be maintained and reducing the enzymatic activity on small peptide substrates of the mutants. These mutations can be introduced using the QuickChange kit (Stratagene) and by following the manufacturer's recommendations and according to the publication Wang & Malcolm (1999)—BioTechniques, 26: 680-682. These mutations can relate to the arginine 142 of the heavy chain of GDXa (numbering according to SEQ ID No. 2) which can be mutated to give any other amino acid, preferably phenylalanine (for example SEQ ID No. 10), glycine (for example SEQ ID No. 11), isoleucine (for example SEQ ID No. 12) or tyrosine (for example SEQ ID No. 13). This mutation can relate to replacement of the peptide sequence of human FXa Arg-Gln-Ser-Thr-Arg-Leu (139-143 of the heavy chain) with the equivalent sequence obtained from bovine FXa: Arg-Leu-Ser-Ser-Thr-Leu (for example SEQ ID No. 26). Similarly lysine 82 of the heavy chain (numbering according to SEQ ID No. 2) can also be replaced by an amino acid such as tyrosine (for example SEQ ID No. 9).
The nucleotide sequence coding for GDXa can be synthesized chemically (Young L and Dong Q., 2004, Nucleic Acids Res., April 15; 32(7), Hoover, D. M. and Lubkowski, J. 2002. Nucleic Acids Res., 30, Villalobos A, et al., 2006. BMC Bioinformatics, June 6; 7: 285). The nucleotide sequence coding for GDXa can also be amplified by PCR using suitable primers.
GDXA can also be produced by genetic engineering techniques that are well known by a person skilled in the art. The nucleotide sequence coding for the human factor X can thus be cloned into an expression vector; part of the nucleotide sequence coding for the signal peptide, the propeptide and domain Gla is deleted, a signal peptide is fused, such as that of TIMP-1 (Crombez et al., 2005). The modified factor X thus produced can be activated either by the complex TF-FVIIa, or by any other enzyme that cleaves the bond between arginine 234 and isoleucine 235 (numbering according to Swiss-Prot: P00742.2). Alternatively, GDXa can be produced directly by insertion of a cleavage sequence recognized by furins or any other intracellular enzyme, directly upstream of isoleucine 235; a sequence coding for these amino acids such as arginine-lysine-arginine permits cleavage by furins (Nakayama et al., 1997). To improve cleavage, a sequence arginine-lysine-arginine-arginine-lysine-arginine can be introduced. The DNA coding for said modified FX is inserted in an expression plasmid and inserted in an ad hoc cell line for production thereof (for example the HEK-393E line), the protein thus produced then being purified by chromatography.
These techniques are described in detail in the reference manuals: Molecular cloning: a laboratory manual, 3rd edition—Sambrook and Russel eds., (2001) and Current Protocols in Molecular Biology—Ausubel et al. eds (2007).
Thus, the GDXa's can also be represented by their nucleotide sequences coding for the GDXa's mentioned above, such sequences being represented by the following sequence identifiers: SEQ ID No. 8, SEQ ID No. 16 to SEQ ID No. 19 for the light chains and by SEQ ID No. 15 or SEQ ID No. 21 to 25 and SEQ ID No. 27 for the heavy chain.
A modified factor of this kind is well known from the prior art (Morita and Jackson, 1986; Skogen et al., 1984, Padmanabhan et al., 1993. J. Mol. Biol., 232: 947-966 or US2009/2298119).
The pharmaceutical composition according to the present invention can be formulated as any dosage form necessary for its administration. In particular, in the case of systemic administration, the composition according to the invention can be formulated in the form of sterile lyophilized powder for injection. The pharmaceutical compositions according to the present invention can also be administered nasally or parenterally. They can therefore comprise, in addition to the active principles, any pharmaceutically acceptable formulation additive, known by a person skilled in the art and that is necessary for preparing the pharmaceutical composition in the desired form and notably any excipient capable of stabilizing the lyophilized protein GDXa after reconstitution with an aqueous solution for subsequent injection thereof.
In the case of a hemorrhagic accident, the pharmaceutical composition according to the present invention can be administered at a concentration 10 to 20 times lower than the recombinant FVIIa (Novoseven®), which is administered according to a posology in the range from 90 to 270 μg/kg per dose administered. Thus, according to another aspect, the present invention also relates to a pharmaceutical composition comprising nonthrombogenic GDXa that can bind to TFPI but cannot bind to the phospholipids, for administration of 4.5 to 27 μg/kg per dose administered, with or without inhibitor, to the patient with hemophilia A or B. Said administration can be by the systemic, nasal or parenteral route.



LEGENDS OF THE FIGURES
FIG. 1. Influence of GDXa or FXa on the generation of thrombin
(A) Tests of production of thrombin in the presence of phospholipids and of TF in a pool of normal plasma (solid line) and in a pool of plasmas of severe hemophilia A (dotted line). (B) hemophiliac plasma enriched with GDXa (50 nM) in the presence of phospholipids and TF (solid line) and without TF (dotted line). (C) hemophiliac plasma enriched with FXa (50 nM) in the presence of phospholipids with TF (solid line) and without TF (dotted line). (D) Cleavage of the substrate ZGGR-AMC by GDXa. Normal plasma pretreated-CTI tested in the presence of phospholipids and of IF with and without (Ctrl-curve A) lepirudin 6 μg/ml in the absence (curve B) or in the presence of various concentrations of GDXa (curves C to E). (E) Generation of thrombin in the presence of phospholipids and of TF in hemophiliac plasma enriched with 10 nM (solid line) or 20 nm (dotted line) of GDXa and (F) with 40 nM (thick line) or 200 nm (dotted line) of rFVIIa.
The data are representative of experiments conducted with at least three different plasmas from different severe type A hemophiliacs.
FIG. 2: Influence of anti-AT and anti-TFPI antibodies on thrombin generation in plasmas from hemophiliacs
Different concentrations of anti-human antithrombin (A) or anti-human TFPI (B) antibodies were added to a severe hemophiliac plasma A and were then left for thrombin generation. The antibody concentrations are expressed in g/l for the anti-antithrombin antibodies and in mg/I for the anti-TFPI antibodies. The concentration of GDXa is in nM. HP denotes hemophiliac plasma; NP denotes normal plasma.
(A) Curve A shows hemophiliac plasma, curves B to D show different concentrations of antithrombin antibodies added to the hemophiliac plasma; curve E shows addition of 50 nM of GDXa added to the hemophiliac plasma, and curve F shows the normal plasma. (B) Curve A shows hemophiliac plasma, and curves B to D show different concentrations of anti-TFPI antibodies added to the hemophiliac plasma; curve E shows addition of 50 nM of GDXa added to the hemophiliac plasma, and curve F shows the normal plasma.
FIG. 3: Enzymatic inhibition of GDXa and FXa by TFPI or antithrombin
(A-B) for inhibition of antithrombin, 1.25 nM of FXa (A) or GDXa (B) were incubated in the presence of increasing concentrations of antithrombin (AT: 0 (curve A) to 500 nM (curve F)) at 37° C. Aliquots were taken at different time points (0 to 90 min) and added to the chromogenic substrate PNAPEP 1025.
(C-D) The inhibition of the activity of FXa (C) or GDXa (D) by TFPI was analyzed by the incubation of enzyme of 0.25 nM at 25° C. for 3 h in buffer A in the presence of increasing concentrations of TFPI (0 to 30 nM for GDXa and 0 to 10 nM for FXa).
The data are representative of two different experiments.
FIG. 4: Determination of the pharmacokinetic properties of GDXa and FXa in the plasma
50 nM FXa (A) or GDXa (B) was added to normal plasma, and the whole was incubated at 37° C. Aliquots were taken at different time intervals and were immediately diluted 25 times in buffer A for determining the residual activity. The half-lives were 1.4±0.1 min for FXa and 1.8±0.1 min for GDXa.
The data are the mean values of two different experiments.
FIG. 5: correction of thrombin generation by rVIIa and GDXa
Addition of GDXa (curves C and D) or rVIIa at different concentrations (curves E and F) in a hemophiliac plasma (HP, curve B). NP: Normal plasma (curve A).
The present invention will be illustrated by the following examples.



EXAMPLE
Example 1
Materials and Methods
Materials:
The pools of frozen plasma from normal patients and individual plasmas from patients with hemophilia A or hemophilia B, the phospholipids TGT, Prionex, Corn Trypsin Inhibitor (CTI), the chromogenic substrate PNAPEP 1025, human factor Xa, human GDXa, and the sheep anti-human thrombin antibodies were obtained from Cryopep (Montpellier, France). Human recombinant TFPI was obtained from Sino Biolocal Inc. (Beijing, China). The relipidized recombinant human tissue factor (TF, Innovin) is from Siemens Healthcare Diagnostics (Puteaux, France). The thrombin calibrator, FluCaKit and round-bottomed 96-well microtiter plates (Immulon 2HB, plate with U-shaped bottom) from Diagnostics Stago (Asnières, France) were used for the thrombin generation tests. For the enzyme experiments, flat-bottomed 96-well microtiter plates were from Greiner (Frickenhausen, Germany); sheep anti-TFPI antibodies are from Affinity Biologicals (Sandhill Drive, Canada). The Actichrom assay of TFPI activity from American Diagnostica (Stamford, USA) was used for determining TFPI activity. The antithrombin activity assay (STA-Stachrom antithrombin III) is from Diagnostica STAGO. Enzymatic calculations were performed with PRISM 5.0.
Methods
1) Thrombin Generation Assay (TGA)
Measurements of thrombin generation were carried out by Hemker's method using 1 pM of Tissue Factor (TF) for activating coagulation and in the presence of 30 μg/ml CTI for inhibiting activation of the contact phase of coagulation during the incubation period (van Veen J J, Gatt A, Cooper P C, Kitchen S, Bowyer A E, Makris M. Corn trypsin inhibitor in fluorogenic thrombin-generation measurements is only necessary at low tissue factor concentrations and influences the relationship between factor VIII coagulant activity and thrombogram parameters. Blood Coagul Fibrinolysis. 2008 April; 19(3): 183-9). Briefly, a mixture of 20 μl of TF, 4 μM phospholipids, and 80 μl of plasma were pipetted in triplicate in a microtiter plate. Twenty microliters of Thrombin calibrator with 80 μl of plasma were also deposited by pipette in triplicate in the plate. The plate was then inserted in a Varioskan (Thermofisher, Illkirch, France) with an excitation wavelength set at 390 nm, with an emission wavelength of 460 nm and a pass band of 10 nm. Twenty microliters of FluCaKit (2.5 fluorogenic substrate mM (Z-Gly-Gly-Arg-AMC, ZGGR-AMC) with 0.1 M of CaCl2) were injected into all the wells, thus starting the reaction. The fluorescence signal is read every 20 seconds for 60 min. The raw data on fluorescence intensities were exported to Sigmaplot® 9.0 for mathematical calculations using the 3-wave method described previously (De Smedt E. Advanced thrombinoscopy: PhD thesis, University Maastricht; 2007).
Hereinafter:
ETP denotes endogenous thrombin potential and corresponds to the area under curve;
PH denotes peak height and corresponds to the peak thrombin level;
LT is the latency time and corresponds to the time to reach 2 nM of thrombin;
PT is the peak time and corresponds to the time to obtain the PH.
The various factors GDXa, Xa or Novoseven® are diluted in buffer A comprising 1% Prionex, 18 mM of HEPES, 135 mM of sodium chloride, pH 7.35 and added to hemophiliac plasmas pretreated with CTI at various concentrations.
2) Neutralization of Antithrombin and TFPI by Specific Antibodies
For neutralization of antithrombin, a severe hemophilia A plasma was enriched with different concentrations of sheep IgG anti-human antithrombin antibody (1.8, 3, 5, and 7.5 g/l) and incubated for one hour at 25° C. before being tested in TGA. In parallel, the antithrombin activity was measured on a STAR coagulometer (Diagnostica Stago) with antithrombin III STA-Stachrom reagents.
For neutralization of TFPI, the same hemophilia A plasma was put in contact with different concentrations of sheep anti-human TFPI immunoglobulins (2.5, 5, 10 and 50 mg/l) before being tested in TGA. In parallel, the activity of the TFPI was determined with the Actichrom TFPI activity assay according to the manufacturer's instructions. Briefly, 20 μl of plasma diluted 20 times was incubated at 37° C. in the presence of 20 μl TF/FVIIa for 30 min. Then factor X (FX) was added and the whole was incubated at 37° C. for 15 min before adding EDTA and Spectrozyme FXa. The reaction was stopped 5 min later by adding glacial acetic acid and the absorbance was read at 405 nm.
3) Determinations of Chromogens
3.1) Determination of the Kinetic Constants of GDXa and Xa
For determining GDXa or FXa activity, 0.3 nM of enzyme is incubated for 5 min at 37° C. in a buffer comprising 1% Prionex, 18 mM of HEPES, 135 mM of sodium chloride, pH 8.4. Then the chromogenic substrate PNAPEP 1025 is added at concentrations of 0.33, 0.50, 1, 1.5, and 2.0 mM, and the variation of absorbance is recorded at 405 nm.
3.2) Enzymatic Inhibition of Antithrombin (AT)
Xa or GDXa (1.25 nM) is incubated at 37° C. in buffer A in the presence of increasing concentrations of antithrombin (0 to 500 nM). Aliquots of 200 microliters of the mixture are taken at different time intervals, up to 90 min. Then 50 μl of chromogenic substrate PNAPEP 1025-6 mM is added and the change in absorbance is recorded.
3.3) Enzymatic Inhibition of TFPI
Inhibition of the activity of GDXa or FXa by TFPI was analyzed by incubating the enzyme at 0.25 nM for 3 h at 25° C. in buffer A in the presence of increasing concentrations of TFPI (from 0 to 30 nM for GDXa and from 0 to 10 nM for FXa) in a final volume of 200 μl. Then 50 μl of chromogenic substrate PNAPEP 1025 2.5 mM was added, and the change in absorbance was recorded. Ki* was determined as described previously (Bunce M W, Toso R, Camire R M. Zymogen-like factor Xa variants restore thrombin generation and effectively bypass the intrinsic pathway in vitro. Blood. 2011 Jan. 6; 117(1): 290-8; Baugh R J, Broze G J, Jr., Krishnaswamy S. Regulation of extrinsic pathway factor Xa formation by tissue factor pathway inhibitor. J Biol Chem. 1998; 273(8): 4378-86).
3.4) Determination of the Plasma Half-Life of GDXa and Xa
The plasma half-life of GDXa or Xa was determined by adding normal plasma with 50 nM of GDXa or of Xa. The mixture was then incubated at 37° C. Aliquots were taken from 0 to 60 min and immediately diluted 25 times in buffer A before adding the chromogenic substrate PNAPEP 1025 1.5 mM and determination of residual amidolytic activity, as described previously.
Example 2
Preparation of Modified Factor Xa
The plasmid pTT5 is opened by digestion with HindIII—BamHI enzymes and the genes coding for the signal peptide of TIMP1 with the HindIII and NheI restriction sites and FX lacking the Gla domain with the NheI and BamHI restriction sites are inserted, generating the plasmid pTT5-TIMX (pTT5 spTIMP1 gla less FX). The sequence coding for FX lacking the Gla domain according to the invention with the NheI and BamHI restriction sites was obtained by chemical synthesis (GenScript Corporation). Then a recognition site for furins was introduced upstream of the N-terminal isoleucine of the heavy chain permitting secretion of GDXa directly in the culture medium for purification. The GDXa produced is represented by the sequence identifier SEQ ID No. 3 for its light chain and by SEQ ID No. 2 for its heavy chain.
Example 3
Determination of the Kinetic Parameters of GDXa and FXa
Before analyzing the effect of GDXa on thrombin generation, the GDXa and Fxa were characterized using cleavage of the chromogenic substrate PNAPEP 1025. GDXa showed a similar affinity (Km=0.75±0.05 mM) to FXa (Km=0.64±0.03 mM) and similar catalytic properties: kcat=290±5 s−1 for GDXa and kcat=375±8 s−1 for FXa (Table 1). These results are consistent with the earlier observations obtained with a chromogenic substrate S2222 (Skogen W F, Esmon C T, Cox A C. Comparison of coagulation factor Xa and des-(1-44)factor Xa in the assembly of prothrombinase. J Biol Chem. 1984; 259(4): 2306-10).







TABLE 1







enzymatic properties of GDXa and FXa














Antithrombin
TFPI



Km (mM)
kcat (s-1)
k2 ± SD (10 3.M-1.s-1)
Ki* ± SD (nM)





Xa
0.65 ±
368 ±
1.50 ± 0.04
 0.17 ± 0.031


GDXa
0.71 ±
269 ±
1.57 ± 0.08
0.31 ± 0.04





The results shown correspond to 2 independent measurements performed in triplicate using the chromogenic substrate PNAPEP 1025.






Example 4
Influence of GDXa or FXa on Thrombin Generation
At a concentration of 1 pM, TF is incapable of inducing production of thrombin in severe hemophiliac plasma A, as shown by the dotted line in FIG. 1A. However, in the presence of 50 pM GDXa, clear restoration of thrombin generation was observed (FIG. 1B). GDXa normalizes all the parameters associated with thrombin generation, including the endogenous thrombin potential (ETP), latency time, peak height, and peak time (FIG. 1B, Table 4). The thrombin generation observed was not a direct effect of GDXa on the plasma, as no thrombin was generated in the absence of TF (FIG. 1B, dotted line). This was observed in all the hemophiliac plasmas tested. Moreover, in contrast to GDXa, FXa triggered thrombin generation, even in the absence of TF (FIG. 1 C), as it is directly capable of converting prothrombin to thrombin.
To quantify possible interference by direct cleavage of the substrate ZGGR-AMC by GDXa, increasing amounts of enzyme were added in the presence of a saturating amount (6 μg/ml) of lepirudin (thrombin inhibitor). As shown in FIG. 1D, the raw fluorescence signal was completely cancelled in the presence of lepirudin. In these conditions, GDXa cleaved the substrate ZGGR-AMC in proportion to its concentration. At a concentration of 50 nM, the final signal corresponded to 8% of the fluorescence generated in the absence of lepirudin; at a concentration of 250 nM, the signal represented about 40% of the total fluorescence. However, because the signal is linear, it was included mathematically in the signal of the complex α2-macroglobulin-thrombin in the 3-wave method used for calculating the curves of thrombin concentration and does not affect the results of thrombin generation (De Smedt E. Advanced thrombinoscopy: PhD thesis, University Maastricht; 2007).
The minimum amount of GDXa capable of restoring thrombin generation in the plasma of patients with severe hemophilia A was evaluated. A concentration of 20 nM GDXa gave a curve of thrombin generation in this plasma (FIG. 1E) similar to that observed for normal plasma (FIG. 1A). Moreover, 10 nM GDXa generated a slightly higher signal than that obtained in the presence of 200 nM of rFVIIa (FIG. 1F).
Example 5
Effect of Anti-Antithrombin and Anti-TFPI Antibodies on Thrombin Generation
The anti-antithrombin antibody is able to massively increase ETP with little impact on the kinetic parameters (Table 2 and FIG. 2A). At 7.5 g/l of anti-antithrombin antibody (residual antithrombin activity 9%), ETP climbed to 2716 nM·min and PH reached 76 nM. This contrasts with the effect on the kinetic parameters (LT=6.6 min, PT=31.3 min). Moreover, as indicated previously by Erhardtsen et al. (Blocking of tissue factor pathway inhibitor (TFPI) shortens the bleeding time in rabbits with antibody induced hemophilia A. Blood Coagul Fibrinolysis. 1995; 6(5): 388-94), an anti-TFPI antibody was also able to restore coagulation in a hemophiliac plasma. At concentrations above 10 mg/l of anti-TFPI antibody (residual TFPI activity<30%), all the TGA parameters were corrected in this hemophilia plasma (Table 2). At 10 mg/l (Table 2 and FIG. 2B), ETP and PH increased from 209 to 762 nM·min and from 8 to 79 nM respectively. LT and PT decreased from 13.6 to 3.5 min and from 25.9 to 7.2 min respectively.







TABLE 2





Influence of antithrombin and anti-TFPI antibodies on 


thrombin generation





















GDXa 50



NP
HP
nM





AT activity (%)
—
97
—


TFPI activity (%)
—
98
—


ETP (nM.min-1)
643
209
629


PH (nM)
42
7.7
43


LT (min)
4.9
13.6
3.4


PT (min)
11.3
25.9
8.6















anti-AT
anti-AT
anti-AT 
anti-AT 


anti-AT IgG concentration
IgG
IgG 
IgG
IgG


(g/l)
7.5
5
3
1.8





AT residual activity (%)
9
24
47
66


ETP (nM.min-1)
2716
1279
502
360


PH (nM)
76
41.4
22.5
15.5


LT (min)
6.6
7.2
9.4
9.8


PT (min)
31.3
24.8
21.5
23.8






anti-TFPI 
anti-TFPI 
anti-TFPI 
anti-TFPI 


anti-TFPI Ig concentration
Ig
Ig
Ig
Ig


(mg/l)
50
10
5
2.5





TFPI residual activity (%)
<20
29
53
80


ETP (nM.min-1)
732
762
593
383


PH (nM)
69.5
78.8
31.9
16.5


LT (min)
3.5
3.5
5
7.7


PT (min)
7.5
7.2
12.7
20.3









Various concentrations of human antithrombin antibody or anti-human TFPI antibodies were added to the plasmas of patients with severe hemophilia A prior to the thrombin generation assay.
HP: hemophiliac plasma;
NP: normal plasma.
The antithrombin and TFPI residual activities were measured according to the method described in the materials and methods.
GDXa: hemophiliac plasma with 50 nM GDXa.
The concentrations of anti-AT IgG are expressed in g/l.
The concentrations of anti-TFPI antibody are expressed in mg/l.
Example 6
Enzymatic Inhibition of GDXa and FXa by TFPI and Antithrombin
For irreversible enzymatic inhibition by antithrombin, the profiles of inhibition of GDXa (1.50±0.04×103 M−1·s−1, FIG. 2B) and of Xa were identical (k2=1.57±0.08×103 M−1·s−1, FIG. 2A). TFPI is an inhibitor of slow fixation of FXa (26, 27) and, at a low concentration, a weak inhibitor of GDXa (28-30). Consequently, the inhibition of FXa and of GDXa were compared (Table 1). GDXa showed a lower affinity for TFPI (Ki*=0.31±0.04 nM, FIG. 2D) relative to FXa (Ki*=0.17±0.03 nM, FIG. 2C). Moreover, attainment of equilibrium in this experiment was suggested by the identity of the titration curves after incubation for 18 hours.
Example 7
Plasma Half-Life of GDXa and Xa
Considering the inhibition of GDXa by TFPI and antithrombin, the residual activity after adding 50 nM of GDXa or of FXa in the plasma at 37° C. was evaluated. As shown in FIG. 4A, the activity in the plasma decreased rapidly, a half-life of about 1 min 30 s was observed, and reached a plateau after 20 min for GDXa or FXa as previously indicated for FXa (Bunce M W, Toso R, Camire R M. Zymogen-like factor Xa variants restore thrombin generation and effectively bypass the intrinsic pathway in vitro. Blood. 2011 Jan. 6; 117(1): 290-8). Nevertheless, the effect on thrombin generation was maintained with the passage of time, such as at one hour, when the residual activity of GDXa was about 10% of its initial activity (FIG. 4B), restoration of thrombin generation was maintained. After incubation for 1 min, ETP increased from 0 to 610 nM and was still 478 nm after 60 min (Table 3). A similar correction was also observed for the maximum peak height (75 nM and 38 nM at 1 and 60 min, respectively) as well as for the shift and the peak times (Table 3).







TABLE 3







Effect of GDXa after 1 minute and 1 hour of incubation 


at 37° C. on a severe hemophiliac plasma












1 min
60 min















ETP (nM.min)
610
478



PH (nM)
75
38



PT (s)
6.6
8.8



LT (s)
1.4
2.1







50 nM of GDXa was added to a severe hemophiliac plasma A and was incubated at 37° C. for 1 hour. Aliquots were taken immediately and after 1 hour for measuring thrombin generation.






Example 8
Influence of GDXa on Thrombin Generation in Patients with Severe Hemophilia A with and without Inhibitor and in Patients with Severe Hemophilia B
Thrombin generation was evaluated in plasma samples from five different donors with severe hemophilia A, including one donor with an inhibitor titrated at 50 Bethesda units, and of a plasma from a patient with severe hemophilia B. Thrombin generation was almost undetectable in the six plasmas when coagulation was triggered by 1 pM of TF, whereas it was restored in the presence of 20 and 50 nM GDXa. Table 4 shows that the corrections were observed at various degrees, for all the plasmas and for all the parameters associated with thrombin generation. In the presence of 20 nM GDXa, the ETP observed was 374±128 nM and the PH was 22±11 nM. LT and PT decreased by 5.0±1.5 and 13.9±3.8 min respectively.
Moreover, a dose effect was observed, the values increased to 533±132 nM for ETP and 46±20 nM for PH when 50 nM GDXa was added. LT and PT decreased by 2.8±0.7 and 9.2±2.7 min respectively.







TABLE 4





Influence of GDXa on thrombin generation on 5 different plasmas


from patients with severe hemophilia A with or without inhibitor and of a


plasma from a patient with severe hemophilia B


















ETP (nM.min) 
GDXa 0 nM
GDXa 20 nM
GDXa 50 nM





NP
611
—
—


P1 (HA)
0
536
530


P2 (HA)
0
268
420


P3 (HA)
0
207
330


P4 (HA)
0
466
610


P5 (HA)
215
331
629


P6 (HA + I)
254
425
539


P7 (HB)
282
546
668


Mean ± SD
125 ± 139 
374 ± 128
533 ± 132





PH (nM)
GDXa 0 nM
GDXa 20 nM 
GDXa 50 nM





NP
43
ND
ND


P1 (HA)
0
33
40


P2 (HA)
0
15
26


P3 (HA)
0
13
25


P4 (HA)
0
41
78


P5 (HA)
8
14
43


P6 (HA + I) 
15
28
55


P7 (HB)
13
23
46


Mean ± SD
6 ± 7
22 ± 11
46 ± 20





LT (min)
HP
GDXa 20 nM 
GDXa 50 nM





NP
5.7
ND
ND


P1 (HA)
0
3.1
2.3


P2 (HA)
ND
5.7
3.0


P3 (HA)
ND
4.5
2.9


P4 (HA)
ND
2.7
1.6


P5 (HA)
16
7.3
3.4


P6 (HA + I)
8
4.5
2.5


P7 (HB)
17
5.5
3.3


Mean ± SD
ND
5.0 ± 1.5
2.8 ± 0.7





PT (min)
GDXa 0 nM
GDXa 20 nM 
GDXa 50 nM





NP
12.3
ND
ND


P1 (HA)
0
13.3
11.1


P2 (HA)
ND
17.6
14.1


P3 (HA)
ND
12.9
10.4


P4 (HA)
ND
8.6
7.3


P5 (HA)
30.3
18.9
8.6


P6 (HA + I) 
24.4
12.4
7.4


P7 (HB)
28.9
12.8
7.3


Mean ± SD
ND
13.9 ± 3.8  
9.2 ± 2.7









20 or 20 nM of GDXa was added to the various plasmas immediately assayed for thrombin generation.
Px: plasma x
HA: hemophilia A
HA+I: hemophilia A with inhibitor (hemophilia A with 50 BU of inhibitor)
HB: hemophilia B
Example 9
Comparison Between GDFXa and factor VIIa (rVIIa, Novoseven®) According to the Invention on Thrombin Generation in Subjects with Hemophilia A
FIG. 5 shows that GDXa is much more effective than rVIIa (Novoseven®) for correcting thrombin generation.
At least 500 nM of rVIIa is required for correction according to: ALJAMALI M N, KJALKE M, HEDNER U, EZBAN M, TRANHOLM M. Thrombin generation and platelet activation induced by rFVIIa (NovoSeven®) and NN1731 in a reconstituted cell-based model mimicking hemophilia conditions. Haemophilia. 2009; 15: 1318-26.

## Claims

1. A method of treating a patient with hemophilia A or B comprising administering to the patient a pharmaceutical composition comprising:
a modified factor Xa (GDXa); and
a pharmaceutically acceptable carrier,
wherein the GDXa comprises:
a light chain consisting of the amino acid sequence set forth in SEQ ID NO: 3, and
a heavy chain consisting of the amino acid sequence set forth in SEQ ID NO: 2; wherein the GDXa does not comprise amino acid residues 1-43 of SEQ ID NO:1.

2. The method according to claim 1, wherein the GDXa is administered at a dose of 4.5 to 27 μg/kg by the systemic, nasal or parenteral administration to the patient.

3. The method according to claim 1, wherein the method treats a hemorrhagic syndrome in the patient.

4. The method according to claim 1, wherein the method treats a hemorrhagic accident in the patient.