Characterization of a High-Affinity Fully Human IgG2 Antibody Against Tissue Factor Pathway Inhibitor As a Bypass Agent for the Treatment of Hemophilia

The tissue factor initiated coagulation pathway is intact in patients with hemophilia; however, this pathway is normally inhibited by tissue factor pathway inhibitor (TFPI), resulting in insufficient thrombin generation to stop bleeding and prevent recurrence of bleeding. Antagonizing this natural inhibition through anti-TFPI antibodies is a potential mechanism to effectively restore hemostasis in patients with hemophilia.

A human phage-displayed antibody library was used to identify optimal anti-TFPI antibodies. From the panning campaign, unique antibodies were identified that bound to human TFPI and were cross-reactive to murine TFPI. In vitro characterization demonstrated that 6 of the antibodies could block TFPI activity, partially or completely restoring factor Xa activity. These 6 antibodies also shortened clotting time of hemophilic human (Hem A) plasma in a diluted prothrombin assay. When the ROTEM assay (Tem International GmbH, Basel, Switzerland) was used to measure clotting in human Hem A plasma from congenitally deficient individuals (factor VIII [FVIII] levels <0.38%), anti-TFPI antibodies significantly shortened clotting time, alone or in combination with FVIII or activated factor VII. In addition, the antibodies were effective in shortening clotting time in human blood containing anti-FVIII antibodies, indicating that anti-TFPI antibodies can be applied to inhibitor patients. One of the identified anti-TFPI antibodies was tested in a hemophilia A mice tail vein transection model and improved survival rate to 60%, significantly higher than the 10% survival rate of mice treated with an isotype control antibody. Additionally, combined with low-dose FVIII, this antibody could further increase the survival rate in hemophilic mice, and it was selected for further optimization.

Optimization covered 2 different aspects: (1) affinity maturation to increase its affinity to human and murine TFPI; and (2) sequence optimization to reduce sequence deviation from germ-line sequences and to remove critical residues prone to undergo unwanted chemical modifications during production and/or storage. Both processes consisted of 2 rounds of sequence optimization and screening. Following affinity maturation, target affinity was increased by >200-fold on human and >500-fold on murine TFPI. Sequence optimization was performed on the backbone of the final affinity-matured variant. BAY 1093884, the final optimized variant, is a fully human IgG2 antibody with <10 pM binding affinity to human and murine TFPI.