The present invention is in the field of medicine. More particularly, the present invention relates to bispecific antibody compounds directed against Dickkopf-related protein 1 (Dkk-1) and receptor activator of nuclear factor kappa-B ligand (RANKL). The bispecific antibody compounds of the present invention are expected to be useful in bone healing, for example as an adjunct to spinal fusion surgery and / or in the treatment of osteoporosis, osteopenia, degenerative lumbar spondylolisthesis, degenerative disk disease, osteogenesis imperfecta, or low bone mass disorders.

Bone disorders affect millions of individuals, often causing painful and debilitating symptoms. Some disorders such as osteoporosis, osteopenia, and / or osteogenesis imperfecta may require therapeutic intervention such as an agent which reduces bone resorption and / or increases bone formation. Other disorders, such as degenerative lumbar spondylolisthesis and degenerative disk disease may require therapeutic intervention such as spinal fusion surgery. Spinal fusion is a surgical procedure in which a graft substance (e.g., a bone graft) is inserted between adjacent vertebrae such that the vertebrae fuse thereby limiting or eliminating the range of motion in the joint space between the fused vertebrae. In addition to the above bone disorders, spinal fusions are performed to address pain and morbidity associated with degenerative conditions such as degenerative disc disease (DDD), spondylosis, and spondylolisthesis; congenital deformities, including kyphosis and scoliosis; as well as some vertebral fractures.

Specific types of spinal fusion procedures include posterolateral lumbar fusion (PLF) and interbody fusion (for example, anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF) which differ according to location and angle of approach to the spine). PLF involves placing a graft substance between the transverse processes of adjacent lumbar vertebrae in the posterior of the spine and then securing the vertebrae to metal rods positioned on each side of the vertebrae. Interbody fusion involves removing an intervertebral disc and placing the graft substance into the intervertebral space between adjacent vertebrae, whereby fusion occurs between the graft and the endplates of the adjacent vertebrae. As with PLF, interbody fusion procedures may be stabilized by securing the vertebrae with metal rods, plates, screws, or wire.

During a spinal fusion procedure, a bone graft substitute (BGS) may also be applied to the graft and at the junction between the graft and adjacent vertebrae in order to stimulate new bone growth and fusion between the graft and vertebrae. BGSs often take the form of a moldable gel, putty, paste, or sponge and comprise substances such as bone forming proteins (e.g., bone morpohogenic proteins) and other growth factors (e.g., TGF- beta, PDGF, FGF). Although BGSs provide a means for supplying needed protein necessary for stimulating new bone formation and fusion, harvesting of BGSs presents challenges and BGSs can only be applied during the spinal fusion procedure.

Although spinal fusion procedures have been performed since the early twentieth century, such procedures continue to pose significant risk. Common risks include risk of vertebrae fusion failure (pseudoarthrosis) and the need for revision surgery, postoperative pain and morbidity, and risk of infection which can all lead to potentially long recovery times and increased patient costs. Thus, there remains a need for alternative therapies which could lead to better outcomes for patients. In particular, there remains a need for a systemically-administered pharmaceutical agent which could be used as an adjunct therapy to spinal fusion procedures. Preferably, such systemically-administered pharmaceutical agent will be capable of being administered prior to, during and / or after a spinal fusion procedure. Additionally, such alternative therapy will preferably be capable of demonstrating efficacy in reducing the risks and / or complications associated with spinal fusion procedures and / or in the treatment of osteoporosis, osteopenia, degenerative lumbar spondylolisthesis, degenerative disk disease, or osteogenesis imperfecta. The bispecific antibody compounds of the present invention, directed against Dkk-1 and RANKL, provide an alternative therapy which is expected to meet at least one of the above needs.

Dkk-1 is a member of the Dickkopf family of proteins which binds low-density lipoprotein receptor-related proteins 5/6 (LRP5/6) and disrupts the association of LRP5/6 with Wnt-family protein complexes. Studies have shown that by disrupting the binding of LRP5/6 to Wnt-family proteins, Dkk-1 inhibits the Wnt signaling pathway thereby impairing osteoblastogenesis and bone metabolism. The role played by Dkk-1 in antagonizing the Wnt signaling pathway makes it a viable target for bone formation and repair therapies.

RANKL is a member of the TNF-superfamily of proteins and plays a critical role in bone remodeling. RANKL is expressed by osteoblasts and binds its cognate receptor RANK on the surface of osteoclasts and osteoclast precursor cells. Binding of RANKL to RANK induces the formation, activation, and survival of mature osteoclasts and the stimulation of intracellular signaling cascades leading to increased bone resorption.

Because of its role in bone resorption, inhibition of RANKL is recognized as a mechanism for improving bone mineral density in patients.

Neutralizing antibodies to Dkk-1 and RANKL are known in the art. For example, U.S. Patent No. 8,148,498 discloses Dkk-1 antibodies for use in bone healing and treating cancers. Likewise, U.S. Patent No. 6,740,522 discloses antibodies directed against RANKL, such as Denosumab which is approved for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. Additionally, U.S. Patent No. 8,338,576 discusses possible combination therapies including a Dkk-1 antibody and one of various bone anabolic or anti-resorptive agents, including RANKL inhibitors, for the treatment of bone mass disorders. However, there is no approved combined therapy for inhibiting the activity of both Dkk-1 and RANKL. Thus, there remains a need for an alternative therapy that combines the bone formation properties of a Dkk-1 inhibitor with the anti-bone resorptive properties of a RANKL inhibitor and improves bone healing outcomes in patients such as spinal fusion patients.

One approach to such an alternative therapy may include the co-administration of two different bioproducts (e.g., antibodies). Co-administration requires either injections of two separate products or a single injection of a co-formulation of two different antibodies. While two injections permit flexibility of dose amounts and timing, it is inconvenient to patients both for compliance and pain. Further, while a co-formulation might provide some flexibility of dose amounts, it is often quite challenging or impossible to find formulation conditions having acceptable viscosity in solution (at relatively high concentration) and that permit chemical and physical stability of both antibodies due to different molecular characteristics of the two antibodies. Additionally, co-administration and co-formulation involve the additive costs of two different drug therapies which can increase patient and / or payor costs. As such, there remains a need for alternative therapies for the treatment of bone disorders and preferably such alternative therapies will comprise a bispecific antibody. However, despite the disclosure of anti-Dkk-1 and anti- RANKL antibodies described above, a single neutralizing bispecific antibody that binds both Dkk-1 and RANKL has not been disclosed in the prior art.

The present invention addresses the need for an alternative therapy for bone fusion procedures. More particularly, the present invention provides bispecific antibody compounds capable of inhibiting the activity of both Dkk-1 and RANKL. The bispecific antibody compounds of the present invention provide a pharmaceutical agent suitable for systemic administration and which is capable of being administered prior to, during, and / or after a spinal fusion procedure. Furthermore, the bispecific antibody compounds of the present invention are useful as agents for bone healing, for example as an adjunct to spinal fusion procedures or in treating conditions associated with bone loss or degeneration.

The present invention provides bispecific antibody compounds having four polypeptide chains, two first polypeptide chains and two second polypeptide chains, wherein each first polypeptide chain comprises a single chain variable fragment (scFv) independently linked at the C-terminus of a mAb IgG heavy chain (HC) via a polypeptide linker (LI) and each of the second polypeptide chains comprises a mAb light chain (LC). According to bispecific antibody compounds of the present invention, each HC comprises a heavy chain variable region (HCVR1) with heavy chain complementarity determining regions (HCDRs) 1-3 and each LC comprises a light chain variable region (LCVR1) with light chain complementarity determining regions (LCDRs) 1-3. Additionally, according to bispecific antibody compounds of the present invention, each scFv comprises a light chain variable region (LCVR2) with LCDRs 4-6 and a heavy chain variable region (HCVR2) with HCDRs 4-6. Also, according to bispecific antibody compounds of the present invention, HCVR2 is linked at its N-terminus to LI and linked at its C-terminus to a polypeptide linker (L2) which is linked to the N-terminus of LCVR2. According to particular embodiments of bispecific antibody compounds of the present invention, the amino acid sequence of HCDR1 is given by SEQ ID NO: 9, the amino acid sequence of HCDR2 is given by SEQ ID NO: 10, the amino acid sequence of HCDR3 is given by SEQ ID NO: 11, the amino acid sequence of LCDR1 is given by SEQ ID NO: 15, the amino acid sequence of LCDR2 is given by SEQ ID NO: 16, the amino acid sequence of LCDR3 is given by SEQ ID NO: 17, the amino acid sequence of HCDR4 is given by SEQ ID NO: 12, the amino acid sequence of HCDR5 is given by SEQ ID NO: 13, the amino acid sequence of HCDR6 is given by SEQ ID NO: 14, the amino acid sequence of LCDR4 is given by SEQ ID NO: 18, the amino acid sequence of LCDR5 is given by SEQ ID NO: 19, and the amino acid sequence of LCDR6 is given by SEQ ID NO: 20. In some more particular embodiments, the HC comprises a mAb IgG4 isotype and each LC comprises a mAb kappa light chain.

In some particular embodiments, the present invention provides bispecific antibody compounds having four polypeptide chains, two first polypeptide chains and two second polypeptide chains, wherein each first polypeptide chain comprises a scFv independently linked at the C-terminus of a HC via LI and each of the second polypeptide chains comprises a LC. According to such embodiments, each HC comprises aHCVRl having an amino acid sequence given by SEQ ID NO: 5 and each LC comprises a LCVR1 having an amino acid sequence given by SEQ ID NO: 7.

Additionally, each scFv comprises a HCVR2 having an amino acid sequence given by SEQ ID NO: 6 and a LCVR2 having an amino acid sequence given by SEQ ID NO: 8. According to bispecific antibodies of the present invention, HCVR2 is linked at its N- terminus to LI and linked at its C-terminus to L2 which is linked to the N-terminus of LCVR2. In some even more particular embodiments, the amino acid sequence of LI is given by SEQ ID NO: 21 and the amino acid sequence of L2 is given by SEQ ID NO: 22.

According to further particular embodiments, the present invention provides bispecific antibody compounds having four polypeptide chains, two first polypeptide chains and two second polypeptide chains, wherein the amino acid sequence of each first polypeptide chain is given by SEQ ID NO: 1 and wherein the amino acid sequence of each second polypeptide chain is given by SEQ ID NO: 2.

The present invention also relates to nucleic acid molecules and expression vectors encoding bispecific antibody compounds of the present invention. In an embodiment, the present invention provides a DNA molecule comprising a

polynucleotide sequence encoding the first polypeptide chain, wherein the amino acid sequence of the first polypeptide chain is SEQ ID NO: 1. In an embodiment, the present invention also provides a DNA molecule comprising a polynucleotide sequence encoding the second polypeptide chain, wherein the amino acid sequence of the second polypeptide chain is SEQ ID NO: 2. In a further embodiment, the present invention provides a DNA molecule comprising a polynucleotide sequence encoding the first polypeptide chain having the amino acid sequence of SEQ ID NO: 1, and comprising a polynucleotide sequence encoding the second polypeptide chain having the amino acid sequence of SEQ ID NO: 2. In a particular embodiment the polynucleotide sequence encoding the first polypeptide chain having the amino acid sequence of SEQ ID NO: 1 is given by SEQ ID NO: 3 and the polynucleotide sequence encoding the second polypeptide chain having the amino acid sequence of SEQ ID NO:2 is given by SEQ ID NO:4.

The present invention also provides a mammalian cell transformed with DNA molecule(s) which cell is capable of expressing a bispecific antibody compound comprising the first polypeptide chain and the second polypeptide chain of the present invention. Also, the present invention provides a process for producing a bispecific antibody compound comprising the first polypeptide chain and the second polypeptide chain, comprising cultivating the mammalian cell under conditions such that a bispecific antibody compound of the present invention is expressed. The present invention also provides a bispecific antibody compound produced by said process.

The present invention also provides a pharmaceutical composition comprising a bispecific antibody compound of the present invention and one or more pharmaceutically acceptable carriers, diluents, or excipients. Pharmaceutical compositions of the present invention can be used in the treatment of a spinal fusion patient, whereby such treatment comprises administering to a spinal fusion patient a pharmaceutical composition of the present invention prior to, during, and / or after spinal fusion surgery. In some embodiments, pharmaceutical compositions of the present invention can be used in the treatment of a bone disorder. In some embodiments, pharmaceutical compositions of the present invention can be used in the treatment of at least one of osteoporosis, osteopenia, degenerative lumbar spondylolisthesis, degenerative disk disease, and / or osteogenesis imperfecta whereby such treatment comprises administering to a patient in need thereof a pharmaceutical composition of the present invention.

The present invention also provides a method of treating a spinal fusion patient comprising administering to a spinal fusion patient a therapeutically effective amount of a bispecific antibody compound of the present invention or pharmaceutical composition thereof, wherein said bispecific antibody compound or pharmaceutical composition thereof is administered to said spinal fusion patient prior to, during, and / or after spinal fusion surgery. Additionally, the present invention provides a method of treating a bone disorder comprising, administering to a patient in need thereof a therapeutically effective amount of a bispecific antibody compound of the present invention. Further

embodiments of the present invention provide a method of treating at least one of osteoporosis, osteopenia, degenerative lumbar spondylolisthesis, degenerative disk disease, and / or osteogenesis imperfecta comprising administering to a patient in need thereof a therapeutically effective amount of a bispecific antibody compound of the present invention or pharmaceutical composition thereof.

The present invention also provides a bispecific antibody compound of the present invention or pharmaceutical composition thereof for use in therapy. More particularly, the present invention also provides a bispecific antibody compound of the present invention or pharmaceutical composition thereof for use in the treatment of a spinal fusion patient. Additionally, the present invention provides a bispecific antibody compound of the present invention or pharmaceutical composition thereof for use in the treatment of a bone disorder. Further, the present invention provides a bispecific antibody compound of the present invention or pharmaceutical composition thereof for use in the treatment of at least one of osteoporosis, osteopenia, degenerative lumbar spondylolisthesis, degenerative disk disease, and / or osteogenesis imperfecta

In an embodiment, the present invention also provides the use of a bispecific antibody compound of the present invention or a pharmaceutical composition thereof in the manufacture of a medicament for the treatment of a spinal fusion patient.

Additionally, the present invention also provides a bispecific antibody compound of the present invention or pharmaceutical composition thereof in the manufacture of a medicament for the treatment of a bone disorder. Further, , the present invention also provides a bispecific antibody compound of the present invention or pharmaceutical composition thereof in the manufacture of a medicament for the treatment of at least one of osteoporosis, osteopenia, degenerative lumbar spondylolisthesis, degenerative disk disease, and / or osteogenesis imperfecta.

As referred to herein, the term "bispecific antibody compound" refers to an engineered polypeptide comprising four antigen binding sites. Two of the four antigen binding sites bind Dkk-1 and the other two antigen binding sites bind RANKL. A bispecific antibody compound of the present invention is capable of interacting with, and inhibiting the activity of both human Dkk-1 and RANKL alone or simultaneously. In combining Dkk-1 and RANKL inhibitory properties into a single compound, it is believed that the bispecific antibody compounds of the present invention will demonstrate bone formation and / or anti-bone resorptive effects in patients. Thus, the bispecific antibody compounds of the present invention, or pharmaceutical compositions thereof, may be useful, for example, as adjuncts to spinal fusion surgery and / or in the treatment of one or more bone disorders.

Also, a bispecific antibody compound, as referred to herein, comprises four polypeptide chains, two first polypeptide chains and two second polypeptide chains. Each of the first polypeptide chains is engineered to comprise a single chain variable fragment (scFv) linked at the C-terminus of a mAb heavy chain (HC) by a polypeptide linker (LI). Each of the second polypeptide chains is engineered to comprise a mAb light chain (LC) and form inter-chain disulfide bonds with one of the first polypeptide chains, specifically within the HC of a first polypeptide chain. Each first polypeptide chain is engineered to form inter-chain disulfide bonds with the other first polypeptide chain, specifically between the HC of each of the first polypeptide chains. Each first polypeptide chain is further engineered to form intra-chain disulfide bonds, specifically within the scFv of each respective first polypeptide chain.

The polypeptide chains of the bispecific antibody compounds of the present invention are depicted by their sequence of amino acids fromN-terminus to C-terminus, when read from left to right, with each amino acid represented by either its single letter or three-letter amino acid abbreviation. Unless otherwise stated herein, all amino acids used in the preparation of the polypeptides of the present invention are L-amino acids. The "N-terminus" (or amino terminus) of an amino acid, or a polypeptide chain, refers to the free amine group on the amino acid, or the free amine group on the first amino acid residue of the polypeptide chain. Likewise, the "C-terminus" (or carboxy terminus) of an amino acid, or a polypeptide chain, refers to the free carboxy group on the amino acid, or the free carboxy group on the final amino acid residue of the polypeptide chain.

As referred to herein, a "single chain variable fragment" (scFv) of a first polypeptide chain, refers to a polypeptide chain comprising a heavy chain variable region (HCVR2) and a light chain variable region (LCVR2) linked via a polypeptide linker (L2). Additionally, as referred to herein (and as represented in the following schematic), the HCVR2 of each scFv is: a.) linked, at its N-terminus, to the C-terminus of one HC (of a first polypeptide chain) by a polypeptide linker (LI); and b.) linked, at its C-terminus, to the N-terminus of the LCVR2 of the same scFv via a second polypeptide linker (L2). Linkers LI and L2 are ty pically of about 10 to 25 amino acids in length and rich in one or more of glycine, serine or threonine amino acids.

According to bispecific antibody compounds of the present invention, the HC of each first polypeptide chain is classified as gamma, which defines the isotype (e.g., as an IgG). The isotype may be further divided into subclasses (e.g., IgG _ls IgG ₂ , IgG ₃ , and IgG^. In particular embodiments, bispecific antibody compounds of the present invention comprise mAb heavy chains of the IgG4 type. Each HC is comprised of an N- terminal heavy chain variable region followed by a constant region (CH), comprised of three domains (CHI, CH2, and CH3) and a hinge region.

Additionally, according to bispecific antibody compounds of the present invention each mAb light chain (LC) is classified as kappa or lambda and characterized by a particular constant region as known in the art. In particular embodiments the bispecific antibody compounds of the present invention comprise kappa LCs. Each LC is comprised of an N-terminal light chain variable region (LCVR1) followed by a light chain constant region.

The HCVR1 and LCVR1, of each HC and LC respectively, and HCVR2 and LCVR2, of each scFv, can be further subdivided into regions of hypervariability, termed complementarity determining regions (CDRs), interspersed with regions that are more conserved, termed framework regions (FR). Preferably, the framework regions of the bispecific antibody compounds of the present invention are of human origin or substantially of human origin. Each HCVR1, HCVR2, LCVR1, and LCVR2 of bispecific antibody compounds according to the present invention are composed of three CDRs and four FRs, arranged from amino-terminus to carboxy-terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. Herein the 3 CDRs of each HCVR1 are referred to as "HCDR1, HCDR2, and HCDR3;" the 3 CDRs of each HCVR2 are referred to as "HCDR4, HCDR5, and HCDR6;" the 3 CDRs of each LCVR1 are referred to as "LCDR1, LCDR2, and LCDR3;" and the 3 CDRs of each LCVR2 are referred to as "LCDR4, LCDR5, and LCDR6." The CDRs contain most of the residues which form specific interactions with the antigen. The functional ability of a bispecific antibody compound of the present invention to bind a particular antigen is largely influenced by the CDRs.

As used interchangeably herein, "antigen-binding site" and "antigen-binding region" refers to those portions of bispecific antibody compounds of the present invention which contain the amino acid residues that interact with an antigen and confer to the bispecific antibody compound specificity and affinity for a respective antigen. According to bispecific antibody compounds of the present invention, antigen-binding sites are formed by a HCVR1 / LCVR1 pair (of a LC and HC bound by inter-chain disulfide bonds) and by a scFv HCVR2 / LCVR2 pair. Additionally, according to bispecific antibody compounds of the present invention, antigen-binding sites formed by each HCVR1 / LCVR1 pair are the same (e.g., comprises affinity for a same antigen), and antigen-binding sites formed by each scFv HCVR2 / LCVR2 pair are the same (e.g., comprises affinity for a same antigen). However, according to bispecific antibody compounds of the instant invention, antigen-binding sites formed by each HCVR1 / LCVR1 pair are different (e.g., comprises affinity for a different antigen) from antigen- binding sites formed by each scFv HCVR2 / LCVR2 pair. According to bispecific antibody compounds of the present invention, the antigen-binding site formed by a HCVR1 / LCVR1 pair confers affinity for Dkk-1, whereas the antigen-binding site formed by a HC VR2 / LCVR2 pair confers affinity for RANKL.

The terms "Kabat numbering" or "Kabat labeling" are used interchangeably herein. These terms, which are recognized in the art, refer to a system of numbering amino acid residues which are more variable (i.e., hypervariable) than other amino acid residues in the heavy chain and light chain variable regions of an antibody (Kabat, et al., Ann. NY Acad. Sci. 190:382-93 (1971); Kabat et al., Sequences of Proteins of

Immunological Interest, Fifth Edition, U.S. Department of Health and Human Services, NIH Publication No. 91-3242 (1991)).

The terms "North numbering" or "North labeling" are used interchangeably herein. These terms, which are recognized in the art, refer to a system of numbering amino acid residues which are more variable (i.e., hypervariable) than other amino acid residues in the heavy and light chains variable regions of an antibody and is based, at least in part, on affinity propagation clustering with a large number of crystal structures, as described in (North et al., A New Clustering of Antibody CDR Loop Conformations, Journal of Molecular Biology, 406:228-256 (2011).

Bispecific Antibody Engineering

Significant issues were encountered when attempting to construct a bispecific antibody compound of the present invention. Problems encountered included engineering a single agent which possesses compatible and / or optimal bioactivity for both an increase in bone formation and a decrease in bone resorption. For example, a bispecific antibody compound comprising a Dkk-1 antibody (described in U.S. Patent No. 8,148,498) as one of the mAb or scFv portions, and a known RANKL antibody (such as Denosumab) as the other of the mAb or scFv portions, does not provide an agent having compatible and / or acceptable bioactivity. In fact, studies have shown the

pharmacodynamic effect profile of Denosumab (for decreasing bone resorption) is six months and the half-life is approximately 35-42 days, whereas the pharmacodynamic effect profile of a Dkk-1 antibody as described in U.S. Patent No. 8,148,498 (for increasing bone formation) is one month and the half-life is only approximately 16 days. Such disparate biological activity profiles create an issue for dosing, especially for therapeutic use as an adjunct to spinal fusion therapy (where essential bone healing and fusion are known to take place in the first three months post-surgery). As such, in order to arrive at a bispecific antibody compound possessing the surprising and unexpected characteristics of the present invention, pharmacological intervention is needed. As a result of the significant issues detailed above relating to engineering a bispecific antibody compound of the present invention, in order to arrive at a therapeutic bispecific antibody possessing a bioactivity profile acceptable for use as an adjunct to spinal fusion surgery, a novel RANKL antibody was developed and engineered. As such, a bispecific antibody compound comprising a Dkk-1 mAb portion and a RANKL scFv portion (described in further detail herein) was engineered. Hie engineered bispecific antibody compounds of the present invention comprise therapeutically acceptable and compatible bioactivity profiles for bone resorption (decrease) and bone formation (increase) for use as an adjunct to spinal fusion surgery. Additionally and surprisingly, the engineered modifications resulted in a bispecific antibody also possessing

therapeutically acceptable stability, solubility, photostability, thermostability, and viscosity. None of the modifications resulting in the bispecific antibody compounds of the present invention are routine or common general knowledge suggested or taught in the art.

Bispecific Antibody Expression

Expression vectors capable of directing expression of genes to which they are operably linked are well known in the art. Expression vectors can encode a signal peptide that facilitates secretion of the polypeptides) from a host cell. The signal peptide can be an immunoglobulin signal peptide or a heterologous signal peptide. Each of the first polypeptide chains and the second polypeptide chains may be expressed independently from different promoters to which they are operably linked in one vector or, alternatively, the first and second polypeptide chains may be expressed independently from different promoters to which they are operably linked in two vectors - one expressing the first polypeptide chain and one expressing the second polypeptide chain. Exemplary suitable vectors for use in preparing bispecific antibody compounds of the present invention include vectors available from Lonza Biologies such as pEE 6.4 (for expressing the first polynucleotide sequence for example) and pEE 12.4 (for expressing the second polynucleotide sequence for example).

A particular DNA polynucleotide sequence encoding an exemplified first polypeptide chain (comprising a scFv linked at the C -terminus of a HC via a flexible glycine serine linker) of a bispecific antibody compound of the present invention having the amino acid sequence of SEQ ID NO: 1 is provided by SEQ ID NO: 3 (the DNA polynucleotide sequence provided by SEQ ID NO: 3 also encodes a signal peptide). A particular DNA polynucleotide sequence encoding an exemplified second polypeptide chain (comprising a LC) of a bispecific antibody compound of the present invention having the amino acid sequence of SEQ ID NO: 2 is provided by SEQ ID NO: 4 (the DNA polynucleotide sequence provided by SEQ ID NO: 4 also encodes a signal peptide).

A host cell includes cells stably or transiently transfected, transformed, transduced, or infected with one or more expression vectors expressing a first polypeptide chain, a second polypeptide chain or both a first and a second polypeptide chain of the present invention. Creation and isolation of host cell lines producing a bispecific antibody compound of the present invention can be accomplished using standard techniques known in the art. Mammalian cells are preferred host cells for expression of bispecific antibodies. Particular mammalian cells are CHO, NSO, DG-44 and HEK 293. Preferably, the bispecific antibody compounds are secreted into the medium in which the host cells are cultured, from which the bispecific antibody compounds can be recovered or purified by conventional techniques. For example, the medium may be applied to and eluted from a Protein A or G affinity chromatography column and size exclusion or Capto multimodal chromatography using conventional methods. Additionally, soluble aggregate and multimers may be effectively removed by common techniques, including size exclusion, hydrophobic interaction, ion exchange, or hydroxyapatite

chromatography. The product may be immediately frozen, for example at -70°C, or may be lyophilized.

It is well known in the art that mammalian expression of antibodies results in glycosylation. Typically, glycosylation occurs in the Fc region of the antibody at a highly conserved N-glycosylation site. N-glycans typically attach to asparagine. By way of example, each HC of the exemplified bispecific antibody compound presented in Table 1 (below) is glycosylated at asparagine residue 296 of SEQ ID NO: 1.

Therapeutic Uses

As used herein, "treatment" and/or "treating" are intended to refer to all processes wherein there may be a slowing, interrupting, arresting, controlling, or stopping of the progression of the disorders described herein, but does not necessarily indicate a total elimination of all disorder symptoms. Treatment includes administration of a bispecific antibody compound of the present invention, or pharmaceutical composition thereof, for treatment of a disease or condition in a patient that would benefit from a decreased level of Dkk-1 and / or RANKL or decreased bioactivity of Dkk-1 and / or RANKL, and includes: (a) inhibiting further progression of the disease, i.e., arresting its development; and (b) relieving the disease, i.e., causing regression of the disease or disorder or alleviating symptoms or complications thereof. The bispecific antibody of the present invention is expected to be useful in bone healing, for example as an adjunct to spinal fusion surgery and / or in the treatment of osteoporosis, osteopenia, degenerative lumbar spondylolisthesis, degenerative disk disease, or osteogenesis imperfecta.

The terms "patient," "subject," and "individual," used interchangeably herein, refer to a human. In some embodiments, a patient is a human that has been diagnosed as in need of, is undergoing, or has previously undergone a spinal fusion procedure. In some embodiments, a patient is a human that is characterized as being at risk of needing or in need of bone healing, for example bone building, bone remodeling, fracture repair, prevention of bone loss of degeneration, and / or as being at risk of developing or in need of treatment for a bone disorder such as osteoporosis, osteopenia, degenerative lumbar spondylolisthesis, degenerative disk disease, or osteogenesis imperfecta.

Pharmaceutical Composition

Bispecific antibody compounds of the present invention can be incorporated into a pharmaceutical composition suitable for administration to a patient. The bispecific antibody compounds of the present invention are intended for administration via parental routes including, intravenous, intramuscular, subcutaneous, or intraperitoneal.

Additionally, bispecific antibody compounds of the present invention may be

administered to a patient alone or with a pharmaceutically acceptable carrier and / or diluent in single or multiple doses. Such pharmaceutical compositions are designed to be appropriate for the selected mode of administration, and pharmaceutically acceptable diluents, carriers, and / or excipients such as dispersing agents, buffers, surfactants, preservatives, solubilizing agents, isotonicity agents, stabilizing agents and the like are used as appropriate. Said compositions can be designed in accordance with conventional techniques disclosed in, e.g., Remington. The Science and Practice of Pharmacy, 19 ^th Edition, Gennaro, Ed., Mack Publishing Co., Easton, PA 1995 which provides a compendium of formulation techniques as are generally known to practitioners. Suitable carriers for pharmaceutical compositions include any material which, when combined with a bispecific antibody compound of the present invention, retains the molecule's activity and is non-reactive with the patient's immune system. A pharmaceutical composition of the present invention comprises a bispecific antibody compound and one or more pharmaceutically acceptable carriers, diluents, or excipients.

An effective amount of a bispecific antibody compound of the present invention refers to an amount necessary (at dosages and for periods of time and for the means of administration) to achieve the desired therapeutic result. An effective amount of the bispecific antibody compound or pharmaceutical composition thereof may vary according to factors such as the disease state, age, sex, and weight of the individual, and the ability of the bispecific antibody compound or portion(s) thereof to elicit a desired response in the individual. An effective amount is also one in which any toxic or detrimental effect of the bispecific antibody compound is outweighed by the therapeutically beneficial effects.

Examples

Bispecific Antibody Expression and Purification

An exemplified bispecific antibody of the present invention is expressed and purified essentially as follows. A glutamine synthetase (GS) expression vector containing the DNA of SEQ ID NO: 3 (encoding an exemplified first polypeptide chain of SEQ ID NO: 1 and a post-translationally cleaved signal peptide) and SEQ ID NO: 4 (encoding an exemplified second polypeptide chain of SEQ ID NO: 2 and a post-translationally cleaved signal peptide) is used to transfect a Chinese hamster cell line (CHO, GS knockout), by electroporation. The expression vector encodes a SV Early (Simian Virus 40E) promoter and the gene for GS. Expression of GS allows for the biochemical synthesis of glutamine, an amino acid required by the CHO cells. Post-transfection, cells undergo bulk selection with 50μΜ L-methionine sulfoximine (MSX). The inhibition of GS by MSX is utilized to increase the stringency of selection. Cells with integration of the expression vector cDNA into transcriptionally active regions of the host cell genome can be selected against CHO wild type cells. Transfected pools are plated at low density to allow for close-to-clonal outgrowth of stable expressing cells. The masterwells are screened for bispecific antibody expression and then scaled up in serum-free, suspension cultures to be used for production.

Clarified medium, into which the exemplified bispecific antibody has been secreted, is applied to a Protein A affinity column that has been equilibrated with a compatible buffer such as phosphate buffered saline (pH 7.4). The column is washed to remove nonspecific binding components. The bound bispecific antibody is eluted, for example, by pH gradient and neutralized for example with Tris, pH 8 buffer. Bispecific antibody fractions are detected, such as by SDS-PAGE or analytical size-exclusion, and men are pooled. Soluble aggregate and mummers may be effectively removed by common techniques including size exclusion, hydrophobic interaction, Capto multimodal chromatography, ion exchange, or hydroxyapatite chromatography. The bispecific antibody is concentrated and / or sterile filtered using common techniques. The purity of the exemplified bispecific antibody after these chromatography steps is greater than 98% (monomer). The bispecific antibody may be immediately frozen at -70°C or stored at 4°C for several months.

The relationship of the various regions and linkers comprising an exemplified bispecific antibody compound of the present invention, expressed and purified following procedures essentially as described above, is presented in Table 1 (numbering of amino acids applies linear numbering; assignment of amino acids to variable domains is based on the International Immunogenetics Information System ^® available at www.imgt.org; assignment of amino acids to CDR domains is based on the well-known Kabat and North numbering conventions as reflected at the end of Table 1):

Table 1: Amino acid regions of an exemplified bispecific antibody of the present invention.

The exemplified bispecific antibody compound presented in Table 1 comprises two first polypeptide chains having amino acid sequences of SEQ ID NO: 1 and two second polypeptide chains having amino acid sequences of SEQ ID NO: 2. According to the exemplified bispecific antibody compound, each of the first polypeptide chains forms an inter-chain disulfide bond with each of the second polypeptide chains between cysteine residue 133 of SEQ ID NO: 1 and cysteine residue 214 of SEQ ID NO: 2; at least two inter-chain disulfide bonds with the other first polypeptide chain, the first inter-chain disulfide bond forming between cysteine residue 225 (of SEQ ID NO: 1) of the first polypeptide chain and cysteine residue 225 (of SEQ ID NO: 1) of the other first polypeptide chain, the second inter-chain disulfide bond forming between cysteine residue 228 (of SEQ ID NO: 1) of the first polypeptide chain and cysteine residue 228 (of SEQ ID NO: 1) of the other first polypeptide chain; and an intra-chain disulfide bond formed in the scFv of each first polypeptide chain between cysteine residue 504 (of SEQ ID NO: 1) and cysteine residue 706 (of SEQ ID NO: 1) of each respective first polypeptide chain. Further, the exemplified bispecific antibody compound presented in Table 1 is glycosylated at asparagine residue 296 of SEQ ID NO: 1 of both first polypeptides.

Except as noted otherwise herein, the exemplified bispecific antibody compound referred to throughout the Examples refers to the exemplified bispecific antibody compound of the present invention presented in Table 1.

Bispecific Antibody Compound Solubility and Stability Analysis

The exemplified bispecific antibody compound is formulated in one of lOmM citrate buffer pH 5.5 or lOmM histidine buffer pH 5.5. The impact of 150 mM NaCl and 0.02% Tween80 added to the respective buffers is also evaluated. The bispecific antibody compound is concentrated in the respective buffer formulations to 1 mg/mL and 50 mg/mL using Ami con U.C. filters (Millipore, catalog # UFC903024).

Stability of the exemplified bispecific antibody compound is analyzed following incubation at 25°C for 4 weeks. Percent high molecular weight (%HMW) is assessed with analytical size exclusion chromatography (aSEC) using a TSKgel Super SW3000 (Tosoh Bioscience product # 18675) column. 50 mM sodium phosphate + 350 mM NaCl, pH 7.0 is used as the mobile phase running at 0.4 mlJmin for 15 minutes. A volume of 5μΙ. (5μ£) of the concentrated bispecific antibody compound is injected into the column and the detection is measured at 214nm. A volume of 1 μΐ, (50μg) is injected into the column and the detection is measured at 280nm. Chromatograms are analyzed using ChemStation and % high molecular weight (HMW) is calculated using the ratio of AUC of the peaks eluted before the monomer peak to total AUC. These results are summarized in Table 2 (the addition of NaCl and Tween did not present any appreciable impact on results).

Table 2: Change in %HMW species from starting control over 4 weeks at 25°C measured bv aSEC.

Solubility of the exemplified bispecific antibody compound is analyzed following incubation at 25°C for one week. Solubility is assessed with bispecific antibody concentrated to 150 mg/mL (using Amicon U.C, filters, Millipore, catalog # UFC903024) and formulated in either lOmM citrate at pH 5.5 including 150mM NaCl or 1 OmM histidine at pH 5.5 including 150mM NaCl. The impact of 0.02% TweenSO added to the respective buffers is also evaluated. The exemplified bispecific antibody exhibited solubility of at least 148 mg/mL, within acceptable values for therapeutic bispecific antibodies (the addition of Tween did not present any appreciable impact on results). The exemplified bispecific antibody compound also lacked phase separation following the incubation period.

Viscosity of the exemplified bispecific antibody compound is analyzed at room temperature. Viscosity is assessed with bispecific antibody compound concentrated to 100 mg/mL (using Amicon U.C, filters, Millipore, catalog # UFC903024) and formulated in either lOmM citrate at pH 5.5 including 150mM NaCl or lOmM histidine at pH 5.5 including 15 OmM NaCl. The exemplified bispecific antibody, when formulated in citrate exhibited a viscosity of 3.12 cP and when formulated in histidine exhibited a viscosity of 4.88 cP, within acceptable values for therapeutic bispecific antibodies.

Photostability analysis of the exemplified bispecific antibody compound is assessed with bispecific antibody concentrated at SO mg/mL and formulated in 10 mM histidine, pH 5.5. Samples are exposed for 240000 lux hour visible light or 40 watt-hr/m ² UV light. Control ("dark") samples are not exposed to light. Samples are then analyzed on an aSEC column for change in %HMW compared to dark samples. When exposed to UV light no change in %HMW was recorded, when exposed to visible light a 1.62 %HMW increase was recorded. Additionally, CDR oxidation and deamidation are not significantly increased by visible light exposure (2.8%) and UV exposure (0.8%).

Photostability measures are all within acceptable values for therapeutic bispecific antibodies.

Freeze thaw analysis of exemplified bispecific antibody compound of the present invention is assessed following three freeze/thaw cycles performed according to Table 3:

Table 3: One Cycle of a Freeze Thaw Analysis.

Freeze/thaw analysis of the exemplified bispecific antibody compound is assessed with bispecific antibody compound concentrated at either 1 mg/mL or 50 mg/mL and formulated in either a) 10 mM citrate, pH 5.5, with and without 0.02% Tween-80; or b.) 10 mM histidine, pH 5.5, with and without 0.02% Tween-80. Three freeze/thaw cycles (a single cycle represented in Table 3) are performed and particle growth for each sample is assessed using a HIAC Particle Counter (Pacific Scientific, p/n. 9703). Results are provided in Table 4.

Table 4: Particle Count Following Freeze/Thaw Analysis.

The results provided in Table 4 demonstrate the exemplified bispecific antibody compound of the present invention, under both low and high concentration conditions, is stable following multiple freeze/thaw cycles.

The results provided herein demonstrate the exemplified bispecific antibody compound of the present invention, formulated as described herein, achieves high protein concentration solubility (greater than 150 mg/mL), displays less man a 0.5% HMW degradation, and possess viscosity and photostability within acceptable values for therapeutic bispecific antibodies.

Bispecific Antibody Binding Affinity to Dkk-1 and RANKL

Binding affinity and binding stoichiometry of the exemplified bispecific antibody to human Dkk-1 and human RANKL is determined using a surface plasmon resonance assay on a Biacore 2000 instrument primed with HBS-EP+ (10 mM Hepes, pH7.4 + 150 mM NaCl + 3 mM EDTA + 0.05% (w/v) surfactant P20) running buffer and analysis temperature set at 25°C. A CM5 chip (Biacore, p/n. BR-100530) containing immobilized protein A (generated using standard NHS-EDC amine coupling) on all four flow cells (Fc) is used to employ a capture methodology. Antibody samples are prepared at 0.2-10 μg/mL by dilution into running buffer. Human Dkk-1 samples are prepared at final concentrations of lOOnM, 50nM, 25nM, 12.5nM, 6.25nM, 3.125nM, 1.5625nM, 0.78125nM, 0.390625nM, 0.1953125nM, and 0 (blank) nM by dilution into running buffer. Human RANKL are prepared at final concentrations of lOOnM, 50nM, 25nM, 12.5nM, 6.25nM, 3.125nM, 1.5625nM, 0.78125nM, 0.390625nM, 0.1953125nM, and 0 (blank) nM by dilution into running buffer.

Each analysis cycle consists of (1) capturing antibody samples on separate flow cells (Fc2 and Fc3); (2) injection of each human Dkk-1 concentration over all Fc at 50 μΐνπιϊη for 300 seconds followed by return to buffer flow for 1200 seconds to monitor dissociation phase; (3) injection of each human RANKL concentration over all Fc at ΙΟΟμΐνητΐη for 150 seconds followed by return to buffer flow for 1800 seconds to monitor dissociation phase; (4) regeneration of chip surfaces with injection of 10 mM glycine, for 120 seconds at 5 over all cells; and (5) equilibration of chip

surfaces with a 10 μL (60-sec) injection of HBS-EP+. Data are processed using standard double-referencing and fit to a 1 : 1 binding model using Biacore 2000 Evaluation software, version 2.0.3, to determine the association rate (k _on , M ^-1 s ^-1 units), dissociation rate (kgff, s ^-1 units), and Rmax (RU units). The equilibrium dissociation constant (KD) is calculated from the relationship K and is in molar units. Results are provided in Table 5.

Neutralization of Dkk-1 Induced Reduction in Luciferase Activity in Vitro

Murine preosteoblastic MC3T3El/Topflash cells which have been stably infected with TCF/LEF luciferase reporter are used to assess the ability of the exemplified bispecific antibody presented in Table 1 to neutralize Dkk-1 activity. Wnt3a induces TCF/LEF-regulated luciferase luminescence. Human Dkk-1 blocks Wnt3a-induced TCF/LEF luciferase expression. Neutralization of Dkk-1 activity by the exemplified bispecific antibody is measured through quantification of luciferase luminescence restoration. MC3T3E1 cells are routinely cultured under selective pressure of 1.25μ£/ητ1 puromycin in MEMa media (Gibco, p/n. A 10490-01) containing 10% FBS (Gibco, p/n.10082-147) and lx penicillin/streptomycin (Hyclone, p/n.SV30010). 40,000 MC3T3E1 cells per well (in ΙΟΟμί) are added to the wells of % well tissue culture plates (Costar, p/n.3903). The cells are incubated overnight at 37°C (under 5% C0 ₂ and 95% humidity).

Wnt3a (R&D, p/n.5036-WN) is diluted to 0.33ug/mL and recombinant hDkk-1 is diluted to lug/ml in growth media Growth media supplemented with Wnt3a and hDkk-1 (at the respective concentrations) is used to prepare dose ranges of 300nM to 1.23nM for: a.) exemplified bispecific antibody; b.) a Dkk-1 neutralizing antibody (a Dkk-1 antibody having an IgG4 backbone and the same heavy and light chain variable region sequences as the mAb portion of the exemplified bispecific antibody); and c.) a RANKL

neutralizing antibody (an IgG4 RANKL mAb having the same CDR sequences as the scFv portion of the exemplified bispecific antibody). Growth media is used for "media only" and "media with Wnt3a" controls.

Following overnight incubation, media is removed and cells are treated with respective antibody treatment concentration or control as described above (in duplicate). Cells are then incubated for 3 hours and 30 minutes at 37°C followed by incubation for 30 minutes at room temperature. Following incubation, treatments are removed from the cells and 50μΙ, of Glo Lysis Buffer (Promega, p/n.E266A) is added to the cells. Cells are then lysed with gentle agitation on a plate shaker for between 5 to 10 minutes. Following cell lysis, 50μL· premixed Bright Glo Luciferase Reagent (Promega, p/n.E620) is added and luminescence is measured on a Wallac Victor 1420 Multilabel Plate Reader. EC so values and confidence intervals (CI) for all treatment groups are calculated using a four- parameter logistic regression model with GraphPad Prism 6.

The results demonstrate that the exemplified bispecific antibody of the present invention neutralizes human Dkk-1 blocking of Wnt3 a-induced TCF/LEF luciferase activity. The inhibition is comparable to that observed with the positive control Dkk-1 antibody (with a mean EC so for the exemplified bispecific antibody of 5.30 nM (CI= 4.12 - 6.82nM) nM versus 6.61 (CI= 4.92 - 8.86 nM) for the positive control Dkk-1 antibody). The RANKL antibody and media controls do not neutralize human Dkk-1 from blocking Wnt3a-induced TCF/LEF luciferase in the MC3T3E1 cells at any concentration tested. The results demonstrate the exemplified bispecific antibody of the present invention effectively neutralizes Dkk-1.

Neutralization of RANKL-Induced NF-kB-Driven Luciferase Activity in Vitro

HEK293 cells, which stably co-express human RANK and a NF-kB driven luciferase reporter, are used to assess the ability of the exemplified bispecific antibody presented in Table 1 to neutralize RANKL activity. In the above-described HEK293 cell model, RANK, when bound by human RANKL, induces NF-kB signaling resulting in luciferase luminescence. Neutralization of RANKL binding to RANK, by the exemplified bispecific antibody, is measured by a reduction of luciferase luminescence.

HEK293 cells are routinely cultured under selective pressure of 7(X^g/mL Geneticin (HyClone, p/n.SV30069.01). 25,000 cells/well are added to the wells of 96 well tissue culture plates (Benton Dickinson, p/n.354620) in assay media (50μΙ,

DMEM/F12 (1:3) media (Gibco, p/n.930152DK) containing 5% FBS (Gibco, p/n.10082- 147), 20nM Hepes (HyClone, p/n.SH30237.01), lxGlutaMax (Gibco, p/n.35050-61) and lx penicillin/streptomycin (Hyclone, p/n.SV30010)). Cells are incubated at 37°C (with 5% C0 ₂ and 95% humidity) overnight.

Assay media including lOOng/mL of hRANKL are used to prepare dose ranges of lOOnM to 0.005nM (with 1:3 serial dilutions) for each of: a.) the exemplified bispecific antibody; and b.) a RANKL neutralizing antibody (an IgG4 RANKL mAb having the same CDR sequences as the scFv portion of the exemplified bispecific antibody). Assay medium is used for "media only" and "media with lOOng/ml RANKL" controls. All treatment groups are incubated for 30 minutes at room temperature before being added to cells.

Following overnight incubation of the cells, existing growth media is removed. Cells are resuspended in 50μΙ, of one of the respective antibody treatments (in triplicate) at one of the above concentrations or in a growth media control. Cells are incubated for 18 hours at 37°C (under 5% C02 and 95% humidity). Following incubation, growth media is removed from the cells and cells are suspended in 50μΙ, of BugLite (2.296g DTT (Sigma, p/n.D0632), 1.152g Coenzyme A (Sigma, p/n. C-3019), 0.248g ATP (Sigma, p/n.A7699) in 1L 1% Trition X-100 Lysis Buffer (30 mL Triton X-100 (Fisher, p/n.BP151-500), 3 mL MgCl (Sigma, p/n.M9272), 108.15 mL 1M Trizma HCL (Sigma, p/n.T-3253), 41.85 mL 1M Trizma Base (Sigma, p/n.T-1503) and 817 mL H20)). Cells are then lysed with gentle agitation on a plate shaker for between 5 to 10 minutes.

Following cell lysis, luminescence is measured on a Wallac Victor 1420 Multilabel Plate Reader. IC ₅₀ values for all treatment groups are calculated using a three-parameter logistic regression model with GraphPad Prism 6.

The results demonstrate that the exemplified bispecific antibody of the present invention neutralized human RANKL induced NF-kB driven luciferase luminescence. The inhibition was comparable to that observed with the positive control RANKL antibody (with a mean ICJO for the exemplified bispecific antibody of 1.20nM versus 1.30nM for the positive control RANKL antibody). Media controls did not neutralize human RANKL induced NF-kB driven luciferase luminescence in the HEK293 cell model at any concentration tested. These results demonstrate the exemplified bispecific antibody of the present invention effectively neutralizes RANKL.

In Vivo Efficacy Analysis in Cortical Defect Model

Systemic effects on bone and vertebrae healing, in vivo, are assessed using a rodent cortical defect model. Fourteen week old male athymic nude rats (Harlan, Indianapolis, IN) are maintained on a 12 hour light/dark cycle at 22°C with ad lib access to food (TD 89222 with 0.5%Ca and 0.4%P, Teklad, Madison, WI) and water.

Cortical defect surgery is performed on the mice, essentially as described in Komatsu, et al. (Endocrinology, 150: 1570-1579, 2009). Briefly, on day 0, 2mm diameter holes extending though both the anterior and posterior cortices are drilled through the diaphysis of the left and right femurs. On day 1 post-surgery, mice are divided into 7 groups and given a single intraperitoneal injection of one of: a.) 1.4 mg/kg exemplified bispecific antibody (N=9); b.) 4.2 mg/kg exemplified bispecific antibody (N=9); c.) 14 mg/kg exemplified bispecific antibody (N=9); d.) 42 mg/kg exemplified bispecific antibody (N=9); e.) 3 mg/kg Dkk-1 assay control antibody (an IgG4 Dkk-1 mAb having the same heavy and light chain variable region sequences as the mAb portion of the exemplified bispecific antibody )(N=9); f.) 3 mg/kg RANKL assay control antibody (an IgG4 RANKL mAb having the same CDR sequences as the scFv portion of the exemplified bispecific antibody)(N=9); and g.) 3mg/kg human lgG4 negative control antibody (N=9). On day 35 mice are sacrificed. At days 7, 21 and 35, post-surgery, whole femur bone mass density (BMD) is monitored longitudinally in vivo by quantitative computed tomography (qCT) using GE Locus Ultra CT Scanner (GE Healthcare, London, Ontario, Canada). Results are provided in Table 6. Similarly, at days 7, 21 and 35, post-surgery, BMD is monitored for lumbar vertebrae 5 (LV5) by qCT. Results are provided in Table 7 (data presented as mean ± SE, Dunnett's T test).

Table 6: BMD Analysis at Cortical Defect Site.

BMD at Cortical Defect Site

m /cm ³

The results presented in Table 6 demonstrate that a single dose (of 4.2 mg/kg or higher) of the exemplified bispecific antibody of the present invention increases the BMD at the cortical defect as early as day 21 post surgery as compared to IgG4 control antibody treated rats.

Table 7: BMD Analysis of LV5

The results presented in Table 7 demonstrate that a single dose of the exemplified bispecific antibody of the present invention increases the BMD at LV5 as early as day 21 post surgery as compared to IgG4 control antibody treated rats.

Post-sacrifice, femoral biomechanical load-to-failure analysis, femoral neck stiffness, and vertebral load-to-failure analysis is performed. Femoral biomechanical load-to-failure strength and femoral neck stiffness are analyzed by mounting the proximal half of the femur vertically in a chuck at room temperature and applying a downward force to the femoral head until failure. Vertebrae (LV5) are load-to-failure tested in compression tests using a MTS model 1/S materials testing device and analyzing with TestWorks 4 software (MTS Corp.). Ultimate load is measured as the maximal force sustained by the vertebrae. Results are provided in Table 8.

Table 8: Femoral Stiffness; Femoral Neck Strength; and Vertebral Strength Analysis (Mean + Std. DevA

The results presented in Table 8 demonstrate that a single dose of the exemplified bispecific antibody of the present invention increases the femoral stiffness and femoral neck strength as well as vertebral strength as compared to IgG4 control antibody treated rats.

Osseous Integration Analysis in Vivo

Osseous integration and implant fixation, as well as systemic effects on vertebrae healing, are assessed in vivo using a rodent tibia screw implant model. Twenty-three week old male Sprague-Dawley rats (Charles River Labs., Int ^' l Inc.) undergo surgical implantation of a titanium screw (2 x 4 mm) into the medial lateral side in both hind leg tibiae. One day post-surgery (day 1), rats are divided into 5 groups and given a subcutaneous injection of one of: a.) 3 mg/kg IgG4 negative control antibody (N=9); b.) 3 mg/kg Dkk-1 assay control antibody (an IgG4 Dkk-1 mAb having the same heavy and light chain variable region sequences as the mAb portion of the exemplified bispecific antibody)(N=9); c.) 3 mg/kg RANKL assay control antibody (an IgG4 RANKL mAb having the same CDR sequences as the scFv portion of the exemplified bispecific antibody) (N=9); d.) 4.2 mg/kg exemplified bispecific antibody (N=9); e.) 14 mg/kg exemplified bispecific antibody (N=9); and f.) 4.2 mg/kg exemplified bispecific antibody at both days 1 and 8 (N=9). On day 21 rats are sacrificed.

After sacrifice, both tibiae are removed from each rat, cleaned and fixed in a SO/SO ethanol/saline solution. A biomechanical pull-to-failure force test (at a speed of 10 mm/min) is performed on each tibia ex vivo using an industrial digital force gauge (Mark- 10, Model M3-50, ESM301, Indiana). Additionally, Bone Mineral Content (BMC) change at L5 is also assessed in rats with μΟΤ for assessment of systemic effect. Results of implant pull-to-failure force assessment are provided in Table 9 (data presented as mean ± SE, Dunnett's T test). Results of BMC change at L5 are provided in Table 10 (data presented as mean ± SE, Dunnett's T test). Table 9: Implant Pull-to-Failure Force Analysis.

The results presented in Table 9 demonstrates that both a single and multiple dose(s) of the exemplified bispecific antibody presented in Table 1 increases the implant pull-to-failure force in a concentration (and frequency) dependent manner as compared to IgG4 control antibody treated rats. This data supports a finding that the exemplified bispecific antibody enhances osseous integration and implant fixation.

Table 10: BMC Change Analysis of L5.

The results presented in Table 10 demonstrates that a single dose of a bispecific antibody of the present invention demonstrates a systemic effect improving BMC of L5 following tibial implant as compared to IgG4 control antibody treated rats.

In Vivo Efficacy Analysis in Posterior Lumbar Fusion Model

Systemic effects on bone and vertebrae healing in spinal fusion models, in vivo, are assessed using a rodent posterior lumbar fusion model. Fourteen week old male Sprague-Dawley rats (Charles River Labs., Int'l Inc.), having mass of between 450-530g, undergo left iliac crest surgery for harvesting a bone autograft of 0.5 x 0.5cm. The bone graft is immediately transplanted to decorticated lumbar vertebrae 5 and 6 (L5 and L6) transverse processes in the same rat from which the graft was harvested. In a first study (Study 1), a total of 48 rats undergo transplant surgery; in a second study (Study 2) a total of 60 rats undergo transplant surgery. On the day of surgery (day 0) digital radiographs are taken to ensure graft positioning.

Day 3 post-surgery the Study 1 transplant group rats are divided into 4 groups and given a single subcutaneous injection of one of: a.) 5 mg/kg IgG4 negative control antibody (N=12); b.) 5 mg/kg Dkk-1 assay control antibody (an IgG4 Dkk-1 mAb having the same heavy and light chain variable region sequences as the mAb portion of the exemplified bispecific antibody) (N=12); c.) 5 mg/kg RANKL assay control antibody (an IgG4 RANKL mAb having the same CDR sequences as the scFv portion of the exemplified bispecific antibody) (N=12); and d.) 7.2 mg/kg Dkk-l/RANKL bispecific antibody (slightly varied from the exemplified bispecific antibody of Table 1 at LI, L2, and framework amino acid sequences for HCVR2 and LCVR2) (N=12). On day 28 rats are sacrificed.

Day 3 post-surgery the Study 2 transplant group rats are divided into 5 groups and given a single subcutaneous injection of one of: a.) 1 mg/kg IgG4 negative control antibody (N=12); b.) 1 mg/kg Dkk-1 assay control antibody (an IgG4 Dkk-1 mAb having the same heavy and light chain variable region sequences as the mAb portion of the exemplified bispecific antibody) (N=12); c.) 1 mg/kg RANKL assay control antibody (an IgG4 RANKL mAb having the same CDR sequences as the scFv portion of the exemplified bispecific antibody) (N=12); d.) 1.4 mg/kg Dkk-l/RANKL bispecific antibody (slightly varied from the exemplified bispecific antibody of Table 1 at LI, L2, and framework amino acid sequences for HCVR2 and LCVR2) (N=12); and e.) 7.2 mg/kg Dkk-l/RANKL bispecific antibody (slightly varied from the exemplified bispecific antibody of Table 1 at LI, L2, and framework amino acid sequences for HCVR2 and LCVR2) (N=12). On day 28 rats are sacrificed.

After sacrifice, all rats are assessed for spinal fusion rate and quality. Study 1 transplant group rats are assessed for BMD change, with μΟΤ, at lumbar vertebrae 3 (L3, non-transplant vertebrae) to assess systemic bone effect. Spinal fusion rate and quality is evaluated using 3D micro CT images (μΟΤ40) with a resolution of 36 μπι per voxel. The 3D images obtained are used to assess osseous tissue fusion using a scoring system: 0 = no fusion; 3 = partial fusion; and 5 = full fusion, where fusion rate is the percentage of combined partial and full fusion scores in each group. Results of spinal fusion rate and quality (at L5 and L6) are provided in Table 11 (data presented as mean score ± SE, Fisher exact test). Results of BMD change at L3 (in Study 1 transplant group) are provided in Table 12 (data presented as mean ± SE, Dunnett's T test).

Table 11: Spinal Fusion Rate and Quality Analysis in Posterior Lumbar Fusion Model.

The results presented in Table 11 demonstrates that a single dose of a bispecific antibody of the present invention increases the fusion rate and quality at posterior lumbar fusion sites as early as day 28 days post-surgery as compared to IgG4 control antibody treated rats.

Table 12: BMD Change Analysis of Adjacent Bone in Posterior Lumbar Fusion Model.

The results presented in Table 12 demonstrates that a single dose of a bispecific antibody of the present invention demonstrates a systemic effect improving BMD of adjacent vertebrae bone following a posterior lumbar fusion procedure as early as day 28 days post-surgery as compared to IgG4 control antibody treated rats.

SEP ID NP; 9 - Exemplified HCDR1 (of exemplified bispecific antibody compound of Table 1)

AASGFTFSSYTMS

SEP ID NP; 10 - Exemplified HCDR2 (of exemplified bispecific antibody

compound of Table 1)

TISGGGFGTYYPDSVKG SEP ID NO; 11 - Exemplified HCDR3 (of exemplified bispecific antibody

compound of Table 1)

ARPGYNNYYFDI

SEP ID ISfP; 12 - Exemplified HgDR4 (of exemplified frispecific antibody

compound of Table 1)

KAS GYAFTNYYIE

SEP ID NO; 13 - Exemplified HCDRS (of exemplified bispecific antibody

compound of Table 1¾

VINPGWGDTNYNEKFKG

SEP ID NP; 14 - Exemplified HCDR6 (of exemplified bispecific antibody compound of Table 1)

ARRDTAHGYYALDP

SEP ID NP; IS - Exemplified LCDR1 f of exemplified bispecific antibody compound of Table Ϊ)

HASDSISNSLH

SEP ID NP; 16 - Exemplified LCDR2 (of exemplified bispecific antibody compound ofTaple l)

YYARQSIQ

SEP ID NP; 17 - Exemplified LCDR3 (of exemplified bispecific antibody compound of Table 1)

QQSESWPLH

SEP ID NP; 18 - Exemplified LQDR4 (of exemplified bispecific antifrody compound of Table 1)

KASQNVGTNVA