CROSS-REFERENCE TO RELATED APPLICATION [0001] This application claims the benefit of the following U.S. Provisional Application Nos.: 63/011,921, filed April 17, 2020, and 63/031,192, filed May 28, 2020, the entire contents of each are incorporated herein by reference.

FIELD

[0002] The present developments relate to the use of bioactive peptides for providing therapeutic relief to patients suffering from cytokine release syndrome (CRS). The developments, in the field of biochemistry, molecular biology, and medicine relate to the treatment of cytokine release syndrome (CRS), acute lung injury (ALI), acute respiratory distress syndrome (ARDS), including additional symptoms that develop in seriously ill individuals. More specifically, the developments include compositions of matter, including peptides, and methods of use thereof for interfering and/or inhibiting the interaction of the CD40 complex with CD 154.

BACKGROUND

[0003] Cytokine Release Syndrome

[0004] Many patients with severe COVID-19 may experience cytokine release syndrome (CRS), which may also cause of death (Zhang et al, 2020; Mehta et al, 2020; Ruan et al, 2020).

[0005] Physicians and researchers may characterize CRS as a systemic inflammatory response that may be caused by several factors. Additionally, CRS may be an adverse effect of some monoclonal antibody therapies, most notably, but not limited to, anti-CD3 (OKT3), anti-CD52 (alemtuzumab), anti-CD20 (rituximab), and the CD28 super-agonist, TGN1412. (Lee et al, 2014). Other studies have shown that some instances, immune system related diseases, immune-related therapies, e.g., CAR-T cell therapy, organ transplantation related sepsis, viral infections, and some drugs may lead to CRS. (Zhang et al, 2020; Lee et al, 2014). [0006] Clinicians and researchers alike have contemplated and proposed a number of theories and hypotheses regarding the biological and cellular aspects of CRS. Generally, cytokines are broadly defined to be small proteins, or peptides, released by cells that may have a specific effect on the interaction or communication between cells, or the behavior of cells. Cytokines may include interleukins, lymphokines, and other cell signal molecules, such as tumor necrosis factors (TNFs) and interferons (IFNs), which may trigger inflammation and may assist a body in responding to an infection.

[0007] Thus, one hallmark of CRS may be a sharp increase in the level of many pro- inflammatory cytokines such as interferon-g (IFN- g), tumor necrosis factor a (TNF a), interleukin-2 (IL-2), interleukin-1 alpha and 1 beta (IL-la and IL-lb)and interleukin-6 (IL-6) among others, along with changes in vital signs such as a high fever. (Lee et al, 2014). Additionally, research regarding CRS in mouse models may demonstrate that mortality and cytokine release is dependent on TCRa T cells. (Faulkner et al, 2005).

[0008] Research concerning severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2), which causes COVID-19, shows that the virus (SARS-CoV-2) binds to alveolar epithelial cells and consequently the innate and the adaptive immune system may be activated. (Zhang et al, 2020). Additionally, many other coronaviruses, including SARS-CoV-1 and MERS may also bind to lung epithelium, and in particular to type 2 pneumocytes. Moreover, current research also suggests that influenza can also bind to lung epithelium and cause the innate and adaptive immune systems to be activated. As a result of the activation of the innate and adaptive immune system, the tissues may release many cytokines, including IL-6. Additional research regarding COVID-19 has shown that while there are other comorbidities such as hypertension, cardiovascular disease, and diabetes associated with the disease, fatalities in the most severe cases of COVID-19 may be caused by CRS and may be predicted by increased levels of ferritin and IL-6. (Mehta et al, 2020; Ruan et al, 2020; Zhang et al, 2020). [0009] Several treatment options have been put forward to address and control CRS. One approach uses Actemra ® (Tocilizumab) which is an immunosuppressive drug that is a humanized monoclonal antibody against the IL-6 receptor. Although anecdotal evidence suggests Actemra ® may be efficacious in reducing CRS, no randomized trial has provided direct evidence of IL-6R blockade resulting in reduced incidence or severity of CRS. Another approach to attempt to control CRS utilizes Lenzilumab which is a humanized monoclonal antibody (class IgG 1 kappa) that targets colony stimulating factor 2 (CSF2) / granulocyte- macrophage colony stimulating factor (GM-CSF). Lenzilumab is thought to work by reducing activation of myeloid cells and decreasing the production of IL-1, IL-6, MCP-1, and IP- 10. These treatments that utilize monoclonal antibodies are designed to alter the immune system's response to self-tissues, as they occur during autoimmune diseases such as rheumatoid arthritis or systemic juvenile idiopathic arthritis as with Tocilizumab; or graft versus host disease as with Lenzilumab; however, clinical trials are only now beginning to test these treatment options while COVID-19 continues to spread and cause severe CRS in patients. Moreover, humanized monoclonal antibodies while often functional, may cause a variety of undesirable side effects that may be immediate and/or latent.

[0010] Thus, there may exist a need in the art for alternative compositions and methods for treatment and prevention of CRS. The present developments address this need by describing a novel method for treatment of CRS.

[0011] Acute Respiratory Distress Syndrome

[0012] The alveolar capillary membrane is the thin tissue barrier between the alveolar sacs ("the alveolus") of the lungs and the pulmonary capillaries through which gases, notably oxygen and carbon dioxide, are exchanged. (Fanelli V, et al. J. of Thoracic Disease 5:326-34, 2013). Additionally, the alveolar capillary membrane is actively involved in solute and fluid flux between the alveolar surface, interstitium, and the blood, as well as fluid clearance from the alveolar spaces into interstitial spaces. Proper gas and fluid exchange and regulation at the alveolar capillary membrane is important to proper oxygenation and prevention of hypoxemia (decreased oxygen in the blood) and hypercapnia (increased carbon dioxide in the blood) and a central feature of maintaining health. (Id).

[0013] Alveolar capillary membrane injury is often preceded, initiated, and caused by a wide variety of predisposing insults (Id; Ware, LB Seminars in Respiratory and Critical Care Medicine 27:337- 49, 2006; Brady, V. Critical Care Nursing Clinics of North America 25:7- 13, 2013). Oftentimes alveolar capillary injury can arise following and complicate infection, sepsis, pneumonia, aspirations, trauma, hyperoxia, radiation, hemorrhage, blast exposure, pancreatitis, brain injury, smoke inhalation, transfusions, drug reactions, complex surgery and many other predisposing disorders; however, the reasons for these developments remain unknown. Individuals possessing any pre-disposing disorders or conditions such as those listed above may be more likely to develop Acute Respiratory Distress Syndrome (ARDS). [0014] Alveolar capillary membrane injury is a feature of an can cause syndromes such as ARDS and many other related and similar disorders that are known as shock lung, Da Nang Lung, white lung, adult respiratory distress syndrome, acute lung injury, acute edematous lung injury, wet lung, lung edema, pulmonary edema, and other names that are used as synonyms of alveolar capillary membrane injury. ARDS may also characterized or classified as the often fatal, non-cardiogenic, acute, usually diffuse, edematous, hemorrhagic and/or inflammatory lung injury. ARDS may in many instances lead to multiple organ failure (MOF) and death. Moreover, ARDS may contribute to addition long term disorders including severe muscle weakness, psychiatric disorders, and/or other continuing disabilities with long term consequences.

[0015] The process or events that incite or lead to ARDS may be unclear in some instances; however in other instances ARDS may be brought on by infection with a known viral infection such as the case with severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2), which causes COVID- 19. In either case, that is whether the acute cause is known or unknown, ARDS appears to involve a cytokine-triggered systemic and lung inflammation characterized by increased blood and lung cytokine levels (e.g. IL- 1, IFN- g, TNF-a, and IL- 8) and a rapid influx of inflammatory cells including neutrophils (PMN), lymphocytes, and mononuclear phagocytes into the lung.

[0016] Research supports a role for neutrophils, macrophages, platelets, and T-lymphocytes each playing a role in the development of ARDS. For example, prior experiments and studies have shown that neutrophil depletion may decrease acute edematous lung injury in animal models and the ability of neutrophils to cause acute edematous injury in isolated perfused lungs. However, compared to investigations of neutrophils, macrophages, and platelets, the participation of T-lymphocytes ("T- cells") in ARDS has been relatively underappreciated (Smiley D, et al, Annals NY Acad. Of Sci. 12:1-11, 2010; Lleva R and Inzucchi SE, Curr.

Op. in Endo. Diab. and Obesity 18:110-18, 2011; Van den Berghe et al, NEJM, 345: 1359- 67, 2001). This may be unexpected because T-cells are of important players and early drivers in immune responses and inflammation. [0017] Furthermore, some research has suggested that T-cells may play an important role such as one study that showed that IL-17 producing CD4+ and CD8+ T-cells were increased in lung lavages of ARDS patients. (Smiley D, et al, supra). In addition, RAG (recombination activating gene)- knockout mice developed milder ARDS and less neutrophil migration into the lung. (Lleva R and Inzucchi SE, supra). However, little work has been done regarding CD40+T cells and because of the different functions of T cell subsets, it may be unexpected that CD40+T cells would be involved or contribute to ARDS, or that a bioactive peptide that acts upon the CD40 complex may be able to prevent, modulate, control, inhibit, or in some way affect ARDS.

[0018] Interestingly, no specific evidence exists that hyperglycemia occurs or contributes to ARDS; however, administering intensive insulin to maintain blood glucose at or below 110 mg/dl may reduce morbidity and mortality among critically ill patients in a surgical intensive care unit compared to a group of patients in which blood glucose levels were higher ranging from 140-200 mg/dl. (Van den Berghe G., supra). Remarks and observations of patient with chronic disorders, such as obesity, may implicate a relationship between hyperglycemia, inflammation, and oxidative stress but the effects of acute hyperglycemia on the development of alveolar capillary membrane injury and the effects of hyperglycemia on inflammation remain unclear (de Carvalho VF, et al., Nutrition Hospital 27: 1391-98, 2012).

[0019] Currently, ARDS treatments are limited to mechanical ventilation, which may include airway pressure release ventilation or positive end-expiratory pressure, oxygen therapy, prone positioning, fluid management, extracorporeal membrane oxygenation (ECMO), and in some cases inhaled nitric oxide (NO). However, no pharmaceutical therapies are currently available that treat or remedy the root cause of ARDS or other syndromes associated with the development or acute or chronic consequences of alveolar capillary membrane injury. And according to the National Heart, Lung, and Blood Institute of the NIH, the only medicinal treatments available for the treatment of ARDS appear to be limited to anti-microbials or anti-virals used for treating the pathogen that may be an underlying cause, and therapeutic agents which may provide supportive care, relieve pain, and/discomfort caused by the syndrome.

[0020] Many practitioners and clinicians recognize that ARDS as a disease that is extremely difficult to treat once it has become sufficiently established in a corporeal body. Moreover, practitioners and clinicians acknowledge that the currently available and necessary treatments may be potentially harmful. For example, mechanical ventilation may be associated with complications such as ventilator-associated pneumonia and ventilator-associated lung injury. Further, the use of high concentrations of inspire oxygen needed to avoid hypoxemia may also be potentially toxic to the lung, possibly because they may increase the production of toxic oxygen free radicals. Therefore, a treatment is needed that is effective, and not harmful when given before, during, or after exposure to an ARDS-inciting insult and after ARDS has started.

[0021] CD40, a member of the TNF receptor superfamily, is known to drive inflammatory responses and cytokine production by many immune cells including monocytes, T cells, and dendritic cells. (Wagner, 1996; Poe et al, 1997; Vaitaitis et al, 2014; Ma and Clark, 2009). CD40 may drive the expansion of self-reactive pro-inflammatory T cells, a subpopulation of TCRa CD4 T cells that are characterized by expression of CD40 (Th40 cells). Th40 cells may be responsible for auto- inflammation in Type 1 Diabetes (T1D) and Multiple Sclerosis (MS) as research has demonstrated that Th40 cells express pro-inflammatory cytokines that drive the auto-inflammation in both T1D and MS. (Vaitaitis et al, Immunology, 2017; Waid et al, 2008; Wagner et al, 2002). Moreover, additional and further research interestingly suggests that SARS-like viral particles may induce CD40 expression on dendritic cells. (Bai, et al, 2008).

[0022] CD40 is a 50-kDa integral membrane protein of the tumor necrosis factor receptor (TNF-R) family. It is constitutively expressed as a homotrimer (Foy TM, et al., Ann. Rev. Immunol., 14:591, 1996). In general, stimulation of all CD40-expressing cell types induces operations which contribute to inflammation, such as enhancement of costimulatory and adhesion molecules, and up- regulation of proteolytic enzymes (Mach, F. et al., Atherosclerosis. 137 Suppl:S89-95, 1998).

[0023] CD40's ligand - CD154 - is a 39-kDa protein that belongs to the tumor necrosis factor (TNF) family. CD40 forms a trimer that binds CD 154 at the interface of the three monomers. CD 154 is expressed commonly on cells beyond the surface-expressed CD 154, as CD 154 may also exist in a soluble biologically active form (sCD154) that is shed from the cell surface after activation. The main source of sCD154 is platelets. (Kaufman, J. et al., J. Thrombosis Haemostasis, 5:788-96, 2007). [0024] CD 154 is known to interact with aMp2 (CD 1 lb/CD 18), a5pl (CD49e/CD29), and al lb b3 (CD41/CD61) found on platelets. Moreover, CD154 has been found to interact with several other integrins including aL (CD1 la), aM (CD1 lb), oD (CD1 Id), b4 (CD 104), a3 (CD49c), and a5 (CD49e). Interestingly, Th40 cells are capable of reactivating recombination activating gene (RAG) 1 and 2 which leads to alteration of the TCRs expressed by these mature, peripheral T cells. Such alterations could potentially lead to epitope spreading, thus expanding the TCR repertoire.

[0025] As described above, both CRS and ARDS are potentially deadly conditions and often require intensive and immediate medical attention; however, currently few therapeutic treatment options currently may exist to treat these conditions. Thus, there exists a need in the art for alternative compositions and methods for treatment and prevention of CRS and ARDS. The present developments address this need by describing a novel method for treatment of CRS and ARDS.

SUMMARY

[0026] The present developments provide a novel method for treating, modulating, and/or reducing cytokine release syndrome (CRS). In some instances, CRS may arise as a result of an infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19. In other instances, CRS may arise as a result of an infection with other coronaviruses, influenzas, pneumonia, or any other form of CRS, including those instances caused by medical treatments and physical trauma. The developments hereof may also treat CRS that may not be related to ARDS, ALI, trauma, monoclonal antibodies or other therapies, including but not limited other treatments such as cancer chemotherapy treatments and CAR-T cell treatments that may result in CRS.

[0027] The present developments also relate to methods of treating subjects before, during, and/or after the development of ALI and/or ARDS, with a specific peptide and/or other compounds to simultaneously reduce alveolar capillary membrane injury, CD40+ T cell levels in the blood and lung, and hyperglycemia.

[0028] Thus, the developments and implementations disclosed herein and hereof may include compositions of matter and methods of treating and/or reducing the incidence of cytokine release syndrome (CRS) and acute respiratory distress syndrome (ARDS). These methods include administering to a subject in need of a treatment an effective amount of a peptide to inhibit, interfere, or affect the binding between proteins associated with CD40 complex, including but not limited to CD 154. In these methods, the diseases or disorders may include CRS, ARDS, acute lung injury, severe lung inflammation, emphysema, chronic obstructive pulmonary disease, asthma, bronchitis, pneumonia, pulmonary edema, acute bacterial lung infection, acute viral lung infection, infant respiratory distress syndrome, sepsis, lung trauma, aspiration, pancreatitis, burn, toxin inhalation, pulmonary infection, and/or any other alveolar capillary membrane injury inciting or producing event, and any condition resulting in the cytokine release syndrome or cytokine storm syndrome.

[0029] The developments are based on the knowledge that interaction of CD404igand (CD154 protein) with CD40 protein expressed on T-cells (Th40 cells), is important pathway in inflammatory disorders. While targeting of selected cytokines may be useful in blunting the most severe peak of CRS, it may be advantageous to target several of the pro- inflammatory cytokines at once. A treatment that could possibly achieve that is the unique peptide KGYY15, with a sequence derived from the CD 154 protein. CD 154 (a member of the TNF super family) is the ligand for CD40 and the mouse CD154-derived sequence VLQWAKKGYYTMKSN spans a region with known CD40- interacting amino acids. Thus, the developments hereof may also be based on the elucidation of the critical residues in CD40 and CD 154 that are important for this interaction. The present developments relate to blocking the interaction between a CD40 protein and a CD 154 protein through the use of small peptides that interact with the CD40 protein at a site where the CD 154 protein would normally bind. The present developments also relate to using such peptides to reduce the level of Th40 cells, thereby reducing the severity of disease.

[0030] The inhibitor peptides useful in the methods hereof may be a peptide that binds to CD40. The inhibitor peptide may disrupt, affect, or modify the interaction of CD40 with CD 154 thereby reducing the number of Th40 cells in the subject. The inhibitor peptide may include an amino acid sequence selected from the group of SEQ ID NO: 3, SEQ ID NO: 4, SEQ ID NO: 27, SEQ ID NO: 28, SEQ ID NO: 29, and SEQ ID NO: 30. The bioactive peptide may have the amino acid sequence of SEQ ID: 3. These inhibitor peptides may include a modification selected from phosphorylation and glycosylation, and/or may be linked to a polyethylene glycol (PEG) molecule, and/or may be linked to one or more domains of an Fc region of human IgG immunoglobin, and/or may be linked to an epitope tag polypeptide comprising between 6 and 50 amino acid residues. Additionally, the inhibitor peptides hereof may also include modifications of termini such as acetylation and amidation. Additionally, peptides hereof may include several salt forms including hydrochloride salts, acetate salts, TFA salts, and sodium chloride salts.

[0031] In these methods, the therapeutic peptide hereof may be administered to the lungs of the subject. For example, the peptide may be via an inhaled mist or administered intranasally. Moreover, in these methods the therapeutic peptide hereof may be administered to the subject in combination with a therapeutically effective amount of one or more compounds including N-acetylcysteine (NAC), ergothioneine (ERGO), alpha-lipoic acid, a CD40+T cell reducing or inactivating agent, and a hypoglycemic agent. Administration is described in more detail below; however, the developments hereof contemplate and include IV bolus, infusion, subcutaneous, intramuscular, and oral routes of administration.

[0032] Thus, one aspect of the present disclosure provides a method of treating or reducing the incidence and/or severity of a disease or disorder that results from inflammatory cytokine production, comprising administering to a subject in need of such a treatment an effective amount of a peptide that alters or modulates the binding or interaction between CD40 complex and CD 154 proteins.

[0033] Numerous embodiments are further provided that can be applied to any aspect disclosed herein and/or combined with any other embodiment described.

[0034] For example, in some embodiments, the disease or disorder is selected from the group of cytokine release syndrome (CRS), acute respiratory distress syndrome (ARDS), alveolar capillary membrane injury, and acute lung injury (ALI). In other embodiments, the disease or disorder selected from the group of severe lung inflammation, emphysema, chronic obstructive pulmonary disease (COPD), asthma, bronchitis, pneumonia, pulmonary edema, acute bacterial lung infection, acute viral lung infection, infant respiratory distress syndrome (IRDS), sepsis, lung trauma, aspiration, pancreatitis, bum, toxin inhalation, pulmonary infection, severe blood loss and/or any other alveolar capillary membrane injury inciting or producing event. In still other embodiments, the peptide binds to CD40 complex. In some embodiments, the peptide disrupts or alters the interaction of CD40 complex with CD 154 and reduces the number of Th40 cells in the subject. In some embodiments, the peptide is selected from the group consisting of SEQ ID NO:4, SEQ ID NO:5, SEQ ID NO:6, SEQ ID NO:7, SEQ ID NO:8, SEQ ID NO:27, SEQ ID NO:28, SEQ ID NO:29, SEQ ID NO:30, SEQ ID NO:32, SEQ ID NO:33, and SEQ ID NO:34. In some embodiments, the peptide having an amino acid sequence of SEQ ID NO: 3. In some embodiments, the peptide decreasing an amount of inflammatory cytokine selected from the group of IL-2, IFNy, IL-6, TNFa, and IL-17A. In some embodiments, the peptide comprises a modification selected from phosphorylation, glycosylation, acetylation on the N-terminus and/or amidation on the C- terminus. In some embodiments, the peptide is linked to a polyethylene glycol (PEG) molecule. In some embodiments, the peptide is linked to one or more domains of an Fc region of human IgG immunoglobin. In some embodiments, the Fc region is human IgG hinge, CH2, CH3 region that is fused to at least one of the amino-terminus or carboxyl- terminus of the peptide. In some embodiments, the peptide is administered to the lungs of the subject.

[0035] Another aspect of the present disclosure provides a method of treating or reducing the incidence and/or severity of an acute inflammation disorder, comprising administering to a subject in need of such treatment an effective amount of an inhibitor modulating CD40 cell levels. In some embodiments, the acute inflammation disorder is selected from the group consisting of sepsis, acute lung injury (ALI), acute respiratory distress syndrome (ARDS), severe lung inflammation, emphysema, chronic obstructive pulmonary disease (COPD), asthma, bronchitis, pneumonia, pulmonary edema, acute bacterial lung infection, acute viral lung infection, infant respiratory distress syndrome, lung trauma, aspiration, pancreatitis, burn, toxin inhalation, pulmonary infection and/or any other alveolar capillary membrane injury inciting or producing event. In some embodiments, the inhibitor is a peptide that binds to or otherwise interacts with CD40. In some embodiments, the inhibitor is a peptide that disrupts the interaction of CD40 with CD 154 thereby reducing the number of Th40 cells in the subject. In some embodiments, the inhibitor is a peptide comprising an amino acid sequence selected from the group consisting of SEQ ID NO:2, SEQ ID NO:3, SEQ ID NO:4, and SEQ ID NO:5. In some embodiments, the inhibitor is a peptide comprising the amino acid sequence of SEQ ID NO:4. In some embodiments the inhibitor peptide comprises a modification selected from phosphorylation and glycosylation. In some embodiments, the inhibitor peptide is linked to a polyethylene glycol (PEG) molecule. In some embodiments, the number of ethylene glycol (EG) units in the PEG molecule is between 460 to 1840. In some embodiments, the inhibitor peptide is linked to one or more domains of an Fc region of human IgG immunoglobulin. In some embodiments, the Fc region is a human IgG hinge, CH2, and CH3 region that is fused to at least one of the amino-terminus or carboxyl-terminus of the peptide. In some embodiments, the inhibitor peptide is linked to an epitope tag polypeptide comprising between 6 and 50 amino acid residues. In some embodiments, the inhibitor is administered via IV infusion, subcutaneous injection, intranasally, in pill form or transdermally to the subject. In some embodiments, the inhibitor is administered intranasally. In some embodiments, the method further comprises administering to the subject a therapeutically effective amount of one or more compounds selected from the group consisting of N-acetyl cysteine (NAC), ergothioneine (ERGO), alpha-lipoic acid, a CD40+ T cell reducing or inactivating agent, and a hypoglycemic agent.

[0036] Another aspect provides a method of treating, controlling or preventing hyperglycemia in a subject, with or without diabetes, comprising administering to the subject a composition comprising an amino acid sequence selected from the group consisting of SEQ ID NO:2, SEQ ID NO:3, SEQ ID NO:4, and SEQ ID NO:5, and functional fragments and/or analogs thereof, in an amount and under conditions effective to decrease hyperglycemia in the subject. In some embodiments, the blood glucose levels of the subject are reduced to less than 140 mg/dl, or less than 120 mg/dl, or less than 110 mg/dl. In some embodiments, the blood glucose levels of the subject are maintained greater than 80 mg/dl, or greater than 90 mg/dl, or greater than 100 mg/dl. In some embodiments, the subject is developing an acute inflammation disorder or suspected of developing an acute inflammation disorder or at risk of developing an acute inflammation disorder. In some embodiments, the hyperglycemia in the subject is reduced in the treatment of toxemia, inflammation, infection, bacteremia, sepsis, septic shock, acute lung injury, severe acute respiratory syndrome (SARS), systemic inflammatory response syndrome (SIRS), or multiple organ dysfunction syndrome (MODS). In some embodiments, the levels of insulin used in the hyperglycemic subject are reduced due to the improved control of blood glucose levels. In some embodiments, the levels of ferritin in the circulating blood is lowered as a result of the administration of the peptide. [0037] In yet another aspect of the present disclosure, a peptide is provided that binds to or modulates CD40 complex; alters or modulates the binding or interaction between CD40 complex and CD 154 proteins; and/or treats or prevents a disease or disorder selected from the group of cytokine release syndrome (CRS), acute respiratory distress syndrome (ARDS), alveolar capillary membrane injury, and acute lung injury (ALI).

[0038] Another aspect provides a peptide that disrupts or alters the interaction of CD40 complex with CD 154 and reduces the number of Th40 cells in the subject.

[0039] In some embodiments of any of the aspects provided herein, the peptide is selected from the group consisting of SEQ ID NO: 2; SEQ ID NO: 3; SEQ ID NO: 4, SEQ ID NO:5, SEQ ID NO:6, SEQ ID NO:7, SEQ ID NO:8, SEQ ID NO: 27, SEQ ID NO:28, SEQ ID NO:29, SEQ ID NO:30, SEQ ID NO: 32, SEQ ID NO:33, and SEQ ID NO: 34. In some embodiments, the peptide having an amino acid sequence of SEQ ID NO: 3. In some embodiments, the peptide decreasing an amount of inflammatory cytokine selected from the group of IL-2, IFNy, IL-6, TNFa, and IL-17A. In some embodiments, the peptide comprises a modification selected from phosphorylation, glycosylation, acetylation on the N-terminus and/or amidation on the C-terminus. In some embodiments, the peptide is linked to a polyethylene glycol (PEG) molecule. In some embodiments, the peptide is linked to one or more domains of an Fc region of human IgG immunoglobin. In some embodiments, the Fc region is human IgG hinge, CH2, CH3 region that is fused to at least one of the amino- terminus or carboxyl-terminus of the peptide. In some embodiments, the peptide is administered to the lungs of the subject. In some embodiments, the peptide one or more of affects, decreases, increases, and/or modulates the blood cytokine levels of one or more of IL-Ib, IL-6, TNFa, IFN-g, IL-2, IL-17A, , IL-12, IL-4, IL-10, IL-2rec, IL-5, and/or IL-8. In some embodiments, the peptide one or more of affects or results in changes to one or more of CD3+, CD4+, CD45RA+, CD45RO+, CD8+ and CD19+ lymphocytes, and NK cells. In some embodiments, the peptide one or more of affects or results in changes to one or more of ferritin, high-sensitivity C-reactive protein (hs CRP), and/or LDH. In some embodiments, the administration of the peptide does not cause any abnormal increase in the clotting cascade. [0040] This Summary is neither intended nor should it be construed as being representative of the full extent and scope of the present disclosure. Moreover, references made herein to "the present disclosure" or aspects thereof, should be understood to mean certain implementations of the present disclosure and should not necessarily be construed as limiting all implementations to a particular and/or description. These as well as other alternative and/or additional aspects are exemplified in a number of illustrated alternative and/or additional implementations and applications, some of which are shown in the figures and characterized in the claims section that follows. However, as will be understood by the ordinarily skilled artisan, the above summary and the detailed description below do not describe the entire scope of the developments hereof and are indeed not intended to describe each illustrated embodiment or every implementation of the present developments nor provide any limitation on the claims or scope of protection herein set forth below. Additional features, versions, characteristics and aspects of the present disclosure may become more readily apparent from the Detailed Description, particularly when taken together with the drawings.

BRIEF DESCRIPTION OF THE DRAWINGS [0041] The drawings include:

[0042] FIGs. 1A-1E provide graphs of how certain Th40 cells from TID subjects respond to self-antigens when induced to make pro-inflammatory cytokines. FIG. 1 A compares TNFa expression from TID subjects and controls. FIG. IB compares IFNy expression from TID subjects and controls. FIG. 1C compares IL-6 expression from TID subjects and controls. FIG. ID compares IL-4 expression from TID subjects and controls. FIG. IE compares IL-6 expression from TID subjects and controls. FIG. ID compares Thl and Th2 cells from TID subjects and controls.

[0043] FIGs. 2A and 2B provide dot plots and graphs of memory phenotype Th40 cells from MS patients showing production of both IL-17 and IFNy. FIG. 2 A shows flow cytometry data of total blood lymphocytes gated for CD4 and CD45RO expression to delineate memory cells. Within that population Th40 cells were assayed for IFNy and IL-17 production by intra-cellular staining. Levels of IL-17 and IFNy were determined above isotype controls. FIG. 2B shows levels of IFNy only, IL-17 only and IFNy/IL- 17 double positive cells from 11 RRMS subjects.

[0044] FIGs. 3A-3C provide graphs and charts of Th40 cells producing specific inflammatory cytokines. FIG. 3 A shows data characterizing purified peripheral blood lymphocytes from MS patients with high Th40 cell levels stained for CD3, CD4, CD40 and intracellularly for different cytokines then analyzed by flow cytometry. FIG. 3B shows data characterizing purified peripheral blood lymphocytes from MS patients with low Th40 cell levels stained for CD3, CD4, CD40 and intracellularly for different cytokines then analyzed by flow cytometry. For FIGs. 3 A and 3B, cells were gated on CD4 versus CD40 and CD3 expression was confirmed for Th40 cells then cytokine expression was analyzed within the Th40 population. FIG. 3C shows that IL-6, IFNy, and IL-2 were statistically different between Th40 high and Th40 low (Two- way ANOVA with Sidak's multiple comparisons test).

[0045] FIGs. 4A-4D provide graphs of cytokine levels in CD4+ and Th40 from brain cells of CA/CPR mice. FIG. 4A shows data for lymphocytes isolated from CA/CPR induced mice at 3 hr., 24 hr., 48 hr. and 72 hr. post injury and stained intracellularly for the Thl, pro- inflammatory cytokine TNFa. FIG. 4B shows data for lymphocytes isolated from CA/CPR induced mice at 3 hr., 24 hr., 48 hr. and 72 hr. post injury and stained intracellularly for the Thl, pro-inflammatory cytokine IFNy. FIGs. 4A and 4B show cytokines in total CD4+ T cells. FIG. 4C shows data for lymphocytes isolated from CA/CPR induced mice at 3 hr., 24 hr., 48 hr. and 72 hr. post injury and stained intracellularly for the Thl, pro-inflammatory cytokine TNFa. FIG. 4B shows data for lymphocytes isolated from CA/CPR induced mice at 3 hr., 24 hr., 48 hr. and 72 hr. post injury and stained intracellularly for the Thl, pro- inflammatory cytokine IFNy. FIGs. 4C and 4D show cytokines in the Th40 subset of CD4+ cells

[0046] FIG. 5 provides graphs of IFNy, TNF a, IL-17, IL-10, IL-2, and IL-21 measurements of draining lymph nodes from EAE mice.

[0047] FIG. 6, which includes FIGs. 6A and FIG. 6B, provides graphs of cytokine production of CFA+MOG35-55 challenged mice. FIG. 6A shows cytokine production by Th40 cells from CFA-control and Th40 cells from CFA+MOG challenged mice. FIG. 6B compares cytokine production by Th40 cells to cytokine production by conventional CD4 T cells within either CFA-control (left) or CFA+MOG (right) generated cells. Statistical differences in A were calculated by One-Way ANOVA with Bonferroni post-test. Statistical differences in B were calculated by Two-Way ANOVA.

[0048] FIG. 7 provides several graphs of cytokine production in Th40 cells.

[0049] FIG. 8 provides several graphs of CD40 and CD3 induced cytokine phenotypes differ and galectin-9 alters the production levels. [0050] FIGs. 9A-9C provide graphs of KGYY-15 and its effects on production of inflammatory cytokines of Th40 cells. FIG. 9A shows data for lymphocytes isolated from the peripheral lymph nodes from NOD mice treated with KGYY15 (grey) and control mice (black) and stained for cytokines. FIG. 9B shows data for lymphocytes isolated from the pancreatic lymph nodes from NOD mice treated with KGYY15 (grey) and control mice (black) and stained for cytokines. FIG. 9C shows data for lymphocytes isolated from the spleens from NOD mice treated with KGYY15 (grey) and control mice (black) and stained for cytokines. Bars show cytokine-positive cells within gated CD4+CD40+ cell populations (Th40), represented as a percentage. Data are from three individual mice from each group and are represented as the mean ± SEM. *p<0.05, **p<0.01 by two-tailed unpaired t test. [0051] FIG. 10 provides two graphs which show how KGYY-6 treatment alters IL-10 production by conventional CD4 T cells.

[0052] FIG. 11 provides a graph that shows the effect of KGYY-6 on inflammatory cytokines.

[0053] FIGs. 12A and 12B provide graphs demonstrating how KGYY6 may improve glucose tolerance and insulin sensitivity. FIG. 12A shows that KGYY6 improves glucose tolerance. FIG. 12B shows that KGYY6 improves insulin sensitivity. Graphs represent a statistically significant improvement in glucose tolerance (A; p<0.05) and insulin sensitivity (B; p<0.005). Graphs represent a statistically significant improvement in glucose tolerance (A; p<0.05) and insulin sensitivity (B; p<0.005).

[0054] FIG. 13 provides a chart that shows that mice treated with KGYY-6 decrease production of TGF.

[0055] FIGs. 14A-14C provide charts demonstrating that 15-mer peptide decreases fructosamine levels in T1D dogs. FIG. 14A shows that dog 15-mer peptide treatment significantly decreases fructoseamine levels in TID dogs. FIG. 14B shows that dog 15-mer peptide treatment significantly decreases fructoseamine levels in TID dogs. FIG. 14C shows the fold change observed in fructoseamine levels in in TID dogs administered the dog 15- mer peptide treatment. Levels of fructoseamine were measured before the first infusion and several weeks after initiation of treatment.

[0056] FIGs. 15A-15B provides charts showing that 15-mer peptide decreases blood glucose levels in TID dogs. FIG. 15A shows that a 15-mer peptide used to treat diabetic dogs was able to positively impact and help control blood glucose levels. FIG. 15B shows the same data as FIG. 15A but with the outlier in the treatment group removed.

[0057] FIG. 16 provides several graphs demonstrating the 15-mer peptide may increase c- peptide in T1D dogs.

[0058] FIG. 17 provides a graph showing that KGYY-15 may affect the inflammatory cytokine IFNy.

DETAILED DESCRIPTION

[0059] The developments hereof provide peptides and methods of treating subjects with cytokine release syndrome (CRS). As used herein, the phrase cytokine release syndrome (CRS) may mean any condition whereby a systemic inflammatory response syndrome (SIRS) is triggered by any factor, including but not limited to infections via viruses or bacteria, certain drugs, and physical trauma. The treatments described herein, therefore, may positively modulate or modify the levels or interactions of inflammatory cytokines, thus providing some relief to a patient that may be afflicted with the syndrome.

[0060] The developments hereof also provide peptides and methods of treating subjects with acute respiratory distress syndrome. As used herein, the phrase acute respiratory distress syndrome (ARDS) may include any condition whereby the subject suffers from alveolar capillary membrane injury. Alveolar capillary membrane injury may include any condition whereby the alveolar capillary membrane of a subject has reduced integrity or function. Moreover, in some implementations the treatments described herein, therefore, may increase the capacity of the injured alveolar membrane or it may completely restore lung compliance and the ability of the membrane to conduct gas exchange and/or fluid regulation and/or other vital functions of the alveolar capillary membrane. Moreover, the methods of this disclosure may act upon either the gas exchange conductance properties of the membrane or the fluid regulating properties of the membrane, or both.

[0061] Further, the methods hereof may be used to treat any condition or syndrome involving or causing alveolar capillary membrane injury. Examples of syndromes or conditions involving alveolar capillary injury include, but are not limited to, acute lung injury (ALI), acute respiratory distress syndrome (ARDS), infant respiratory distress syndrome (IRDS), traumatic brain injury (TBI), and neurogenic pulmonary edema (NPE). Some of the predisposing factors that contribute to ARDS may include infection, trauma, shock, lung trauma, surgery, drug reactions, drug overdose, transfusions, salt water inhalation, noxious gas or smoke inhalation, radiation, aspiration, pancreatitis, shock, and hyperoxia exposure. The possibilities are many and drivers and include new pre-disposing causes of alveolar capillary membrane injury as they are discovered. Regardless of the root cause of the membrane injury, these methods can be used to treat or prevent the alveolar membrane, and thus treat ARDS.

[0062] Before the present developments are further described, it is to be understood that these developments are not strictly limited to particular implementations described, as such may of course vary. It is also to be understood that the terminology used herein is for the purpose of describing particular implementations only, and is not intended to be limiting, since the scope of the present developments will be limited only by the claims.

[0063] It must be noted that as used herein and in the appended claims, the singular forms "a," "an," and "the" include plural referents unless the context clearly dictates otherwise. It should further be understood that as used herein, the term "a" entity or "an" entity refers to one or more of that entity. For example, a nucleic acid molecule refers to one or more nucleic acid molecules. As such, the terms "a," "an," "one or more," and "at least one" can be used interchangeably. Similarly, the terms "comprising," "including," and "having" can be used interchangeably.

[0064] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which these developments belong. Although any methods and materials similar or equivalent to those described herein can also be used in the practice or testing of the present developments, the preferred methods and materials are now described. All publications mentioned herein are incorporated herein by reference to disclose and describe the methods and/or materials in connection with which the publications are cited. The publications discussed herein are provided solely for their disclosure prior to the filing date of the present application. Nothing herein is to be construed as an admission that the present developments are not entitled to antedate such publication by virtue of prior invention. Further, the dates of publication provided may be different from the actual publication dates, which may need to be independently confirmed. [0065] It is appreciated that certain features of the developments, which are, for clarity, described in the context of separate implementations, may also be provided in combination in a single implementation. Conversely, various features of the developments, which are, for brevity, described in the context of a single embodiment, may also be provided separately or in any suitable sub- combination. All combinations of the implementations are specifically embraced by the present developments and are disclosed herein just as if each and every combination was individually and explicitly disclosed. In addition, all sub-combinations are also specifically embraced by the present developments and are disclosed herein just as if each and every such sub-combination was individually and explicitly disclosed herein.

[0066] It is further noted that the claims may be drafted to exclude any optional element. As such, this statement is intended to serve as antecedent basis for use of such exclusive terminology as "solely," "only," and the like in connection with the recitation of claim elements or use of a "negative" limitation.

[0067] Furthermore, as used herein the term animal refers to a vertebrate, preferably a mammal, more preferably a human. Suitable mammals on which to use the methods of the present developments include but are not limited farm animals, sports animals, pets, primates, mice, rats, horses, dogs, cats, and humans. The term animal can be used interchangeably with the terms subject or patient.

[0068] As used herein, the term "treatment" means a procedure which ameliorates or prevents one or more causes, symptoms, or unwanted/untoward effects of CRS, ARDS, or alveolar capillary membrane injury in a subject or patient. Similarly, the term "treat" is used to indicate performing a treatment. Treatments described herein, can, but need not, cure the subject, i.e. remove the cause(s), or remove entirely the symptom(s) and/or unwanted/untoward effect(s) of CRS, ARDS, or alveolar capillary membrane injury on the abnormal condition of the subject. Therefore, a treatment may include treating a subject to attenuate symptoms of the illness or injury, the symptoms of which may include, but are not limited to, shortness of breath, tachypnea, or low blood pressure, or may include removing or decreasing the severity of the root cause of the abnormal condition or injury of the subject. Moreover, the treatment may also reduce signs of the distress or injury of the subject that may include hypoxia, hypoxemia, lung and systemic inflammatory and oxidative stress responses that contribute to lung and other organ dysfunction, including multiple organ failure.

[0069] As used herein, the terms "patient" and "a subject" and similar phrases, are intended to refer to subjects who have been diagnosed with CRS, ARDS, or alveolar capillary injury. The terms "Healthy subject", "non-CRS subject", "non-ARDS subject", "a subject who does not have CRS", "a patient who does not have ARDS", and similar phrases, are intended to refer to a subject who has not been diagnosed with CRS, ARDS, or alveolar capillary injury. A healthy subject has no other acute systemic disease.

[0070] As used herein, the term "sample" or "biological sample" includes a sample of any cell type or from any tissue or body fluid, body fluids including, but not limited to: cerebrospinal fluid (CSF), serum, plasma, blood, or fluid from any suitable tissue. In a preferred embodiment, the biological sample is blood or any component of blood (e.g., serum, plasma, etc.).

[0071] As used herein the term "administer," "administering," and "administration" is intended to mean introducing at least one compound into a subject. When administration is for the purpose of treatment, the compound or substance may be provided before, during, and/or after the onset of or progression of a symptom or sign of CRS, ARDS, and/or alveolar capillary membrane injury.

[0072] As used herein, a "symptom" is a subjective manifestation from the point of view of the patent, e.g. shortness of breath.

[0073] A "sign" on the other hand, is an objective, clinical manifestation that is often measurable or quantifiable, e.g. low blood oxygen levels or rapid respiratory rate or an abnormal chest x-ray. The therapeutic administration of compounds and peptides hereof may serve to attenuate any symptom or sign, or prevent additional symptoms or signs from arising. In at least some instances the substance or compound may be provided in advance of any visible or detectable symptom or sign of either alveolar capillary membrane injury, cytokine release syndrome, or acute respiratory distress syndrome. The prophylactic administration of the compounds and peptides hereof may serve to attenuate subsequently arising symptoms or signs or prevent symptoms or signs from arising altogether. For example, a specific peptide hereof, may be administered intravenously in an intensive care unit to individuals who are "at-risk" because of predisposing conditions and/or who have developing or established CRS or ARDS. In at least some instances, the developments hereof, contemplate the peptides hereof being administered to patients who may have contracted COVID-19 and thus have a risk of developing CRS or ARDS simply by their exposure and contraction of the viral illness. Alternatively, other implementations of the developments contemplate oral administration that may be used for mass casualty situations in which the peptide is given by first responders to individuals exposed to an insult as a matter of course.

[0074] Thus, the route of administration of the compounds and peptides hereof includes, but is not limited to, topical, transdermal, intranasal, intralung (insufflation or aerosolization), transmucosal, oral, subcutaneous, intravenous, intraarterial, intramuscular, intraosseous, intraperitoneal, epidural, and intrathecal administration.

[0075] The peptides, compounds, and methods hereof may be useful in decreasing the severity of CRS, ARDS, and/alveolar capillary membrane injury directly and/or by decreasing factors such as CD40+ T cell mediated inflammation and/or hyperglycemia that contributes to ARDS.

[0076] Thus the treatment and prevention methods hereof include administering a therapeutically effective amount of peptides to subjects in need thereof. Peptides useful in these methods include a peptide that has a least a portion of the amino acid sequence of a CD 154 protein such that the peptide interacts with CD40 protein in such a manner as to modulate, affect, interfere, block, change, or otherwise alter the interaction of a CD40 complex with CD154. These peptides may comprise 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 more contiguous amino acids from the human CD40 ligand (CD 154), and interact with CD40 in such a manner as to modulate, affect, interfere, block, change, or otherwise alter the interaction. The peptides may in certain implementations may preferably include a core sequence of lysine-glycine-tyrosine-tyrosine (KGYY; SEQ ID NO: 3 - see Table 1). These peptides may alternatively include at least one sequence selected from the group of SEQ ID NO: 4, 5, 6, 7, 8; SEQ ID NO: 27, 28, 29, 30; and SEQ ID NO: 32, 33, 34. These peptide sequences are set forth in the following Table 1 :

Table 1

SEQ ID NO Description

[0077] The peptides may often have sequences that are entirely responsible for the interaction of the peptide with a CD40 protein; however, the peptides hereof may additionally contain amino acid sequences that do not interact with a CD40 protein as they may have other useful functions as well. For example, in addition to the amino acid sequence responsible for interacting with a CD40 protein, a peptide of the present invention can contain amino acid sequences that are useful for visualizing or purifying the peptide. Such sequences act as labels (e.g., enzymes) or tags (antibody binding sites). Examples of such labels and tags include, but are not limited to, B-galactosidase, luciferase, glutathione-s- transferase, thioredoxin, HIS-tags, biotin tags, and fluorescent tags. Other useful sequences for labeling and tagging proteins are known to those of skill in the art.

[0078] Likewise, peptides of the present invention can be modified, so long as such modification does not significantly affect the ability of the peptide to treat CRS, ARDS, or alveolar capillary membrane injury. Such modifications can be made, for example, to increase the stability, solubility or absorbability of the protein. Examples of such modifications include, but are not limited to pegylation, glycosylation and chemical modification of the peptide.

[0079] Peptides hereof may be formed as a fusion with another peptide that may enhance one or more properties of the peptide. In one version, the peptide may be fused to another peptide that imparts favorable pharmacokinetic characteristics to the peptide. In another example, the peptide may be fused with a peptide that enhances the intracellular transport of the therapeutic peptide. Examples of these peptides may include TAT derived from HIV, antennapedia derived from Drosophilia , VP22 from herpes simplex virus, complementary- determining regions (CDR) 2 and 3 of anti-DNA antibodies, 70 KDa heat shock protein, and transportan. For example, in at least one implementation the HIV internalization peptide YGRKKRRQRRR (SEQ ID NO: 35) may be utilized. Other known variants of this sequence may also be further implemented to confer some additional properties to be used with the peptide. Additional peptides such as XGRKKRRQRRR (SEQ ID NO: 36), where X is an amino acid other than Y may also be utilized in this manner, thus for example GRKKRRQRRR (SEQ ID NO: 37) is a variant of a peptide that may be used as a TAT variant in implementations hereof

[0080] Also contemplated in the context of the methods and compositions hereof is the alteration of the therapeutic peptides by chemical or genetic means. Examples of this type of alteration or modification may include the construction of peptides of partial or complete sequences with non— natural amino acids in L or D enantiomeric forms. Accordingly, any of the peptides hereof and disclosed herein, and any variants, thereof could be produced in all-D form. Additionally, the peptides hereof may be further modified to contain carbohydrate or lipid moieties, such as sugars or fatty acids, covalently linked to the side chains of the N- or C- termini of the amino acids. Furthermore, the peptides may be additionally altered or enhanced by glycosylation and/or phosphorylation. Likewise, the peptides hereof may be acetylated or amidated at N- or C- termini as this may confer desirable properties or characteristics to the peptide.

[0081] In addition to the alterations, modifications, and enhancements previously described, the peptides hereof may be modified to enhance solubility and/or half-life upon being administered. For example, polyethylene glycol (PEG) and related polymers may be used to stabilize the peptide and extend the half-life of the peptide in the blood or patient tissue. A variety of PEG enhancements and modifications are contemplated hereby including two PEG side chains linked via the primary amino groups of a lysine. Moreover, a peptide hereof may be modified by acetylation on the N-terminus and/or amidation on the C-terminus, which may be used to stabilize the peptide.

[0082] In yet another implementation, the peptides hereof may be linked to one or more domains of an Fc region of mouse, human, canine, feline, or equine, IgG immunoglobin, or the equivalent in each species, and/or may be linked to an epitope tag polypeptide comprising between 6 and 50 amino acid residues. In some instances, the peptides and proteins fused to an Fc region have been observed to exhibit substantially greater half-life in vivo than the unfused counterpart. Additionally, a fusion to an Fc region may allow for dimerization/multimerization of the fusion polypeptide. The Fc region may a naturally occurring Fc region, or may be altered to improve certain qualities, including but not limited to therapeutic qualities, circulation time, and reduced aggregation.

[0083] In some implementations, the peptides hereof may also be modified to contain, conjugated to, and/or administered with phosphorus, sulfur, manganese, magnesium, calcium, halogens, metals, etc. Amino acid mimics may be used to produce polypeptides, and therefore, the polypeptides of this disclosure may include amino acids mimics that have enhanced properties, such as resistance to degradation.

[0084] The peptides and methods hereof may also comprise administering pro-drugs that metabolize to an active form of these peptides. As used herein, a "pro-drug" is a compound that a biological system metabolizes to an active compound as a result of spontaneous chemical reaction(s), enzyme catalyzed reaction(s), and/or metabolic chemical reaction(s), or a combination of each. Standard prodrugs are formed using groups attached to functionality, e.g. HO-, HS-, HOOC-, R2N-, associated with the drug, that cleave in vivo. Standard prodrugs include, but are not limited to, carboxylate esters where the group is alkyl, aryl, aralkyl, acyloxyalkyl, alkoxycarbonyloxyalkyl as well as esters of hydroxyl, thiol and amines, where the group attached is an acyl group, an alkoxycarbonyl, aminocarbonyl, phosphate or sulfate. The groups illustrated are exemplary and not exhaustive, and one skilled in the art could prepare other known varieties of prodrugs. Prodrugs must undergo some form of a chemical transformation to produce the compound that is biologically active or is a precursor of the biologically active compound. In some cases, the prodrug is biologically active, usually less than the drug itself, and serves to improve drug efficacy or safety through improved bioavailability, pharmacodynamic half-life, etc.

[0085] The methods of treatment hereof may include co-administering the peptides with a least one additional compound. The term "co-administer" indicates that each of at least two compounds is administered during a time frame wherein the respective periods of biological activity or effects overlap, but they need not be administered simultaneously. Thus, the term "co-administer" includes sequential as well as co-extensive administration of the compounds of the present developments. Similar to "administering," "co-administering" of more than one substance may be for therapeutic and/or prophylactic purposes. If more than one substance is co-administered, the routes of administration of the two or more substances need not be the same. In one specific implementation, the peptide is co-administered with a derivative of L- ergothioneine, N-acetylcysteine (NAC), an organoselenium, a thiol-yielding compound, a glutathione enhancing compound and/or alpha-lipoic acid. The development contemplates the possibility of administering a variety of agents alone and/or in combination with the peptide in any order and by any means. The scope of the developments are not limited by the identity of the substance which may be co-administered.

[0086] In yet another implementation of treatment hereof, the peptides may be provided as a sterile solution in lOmM acetate buffer, in 5% glucose, in water. In this implementation the pH may be approximately 5.5. The peptide in at least one implementation will be provided as a sterile solution in 10 mM acetate buffer, in 5% glucose in water, pH 5.5, 5 mL at 20 mg/mL, 100 mg/vial. On the day of administration, the product will be diluted in saline to result in 50 mL for intravenous (IV) infusion over 30 minutes. The developments hereof further contemplate using alternative buffer systems that may facilitate efficacious delivery and treatment with the peptide.

[0087] One property of the inhibitor peptides provided herein may be that they decrease hyperglycemia during ARDS development. Thus the methods hereof may include treating or preventing hyperglycemia in a subject by administering to the subject a composition comprising a peptide of any one of SEQ ID NOs: 4, 5, 6, 7, 8; SEQ ID NO: 27, 28, 29, 30; and SEQ ID NO: 32, 33, 34, and functional fragments and/or analogs thereof, in an amount and under conditions effective to prevent hypoglycemia. Thus, these methods may include the treatment of both non-diabetic and diabetic subjects.

[0088] The methods hereof may also include the treatment of a subject developing ARDS or suspected of developing ARDS and/or at risk of developing ARDS in order to decrease or prevent hyperglycemia associated with developing ARDS that may exacerbate or intensify the severity or rate of developing ARDS. In these methods, the blood glucose levels of the subject may be reduced to less than 140 mg/dl, or less than 120 mg/dl, or less than 110 mg/dl. In these methods the blood glucose levels of the subject may be maintained greater than 80 mg/dl, or greater than 90 mg/dl, or greater than 100 mg/dl. It should be recognized that these methods are not limited only to treating CRS or ARDS but may also be useful in reducing hyperglycemia in the treatment of toxemia, inflammation, infection, bacteremia, sepsis, septic shock, acute lung injury, severe acute respiratory syndrome (SARS), systemic inflammatory response syndrome (SIRS), or multiple organ dysfunction syndrome (MODS). [0089] It is contemplated hereby, that the peptide and other compounds may be potentially used to pretreat large numbers of potentially exposed individuals before symptoms of CRS or ARDS develop. Practically, a major concern arises if thousands of individuals are exposed simultaneously and unexpectedly to a virus such as COVID-19, that not enough ICU beds and diagnostic tests would be available to afflicted individuals in a timely manner. Thus the methods and compositions of this disclosure provide a potentially safe and reasonable approach at mitigation CRS and ARDS and other serious illnesses following a mass tragedy. These peptides and/or other compounds may even be given by first responders and given to first responders in non-clinical settings to prevent the development of CRS and ARDS.

[0090] When administered or co-administered, the compounds of the present developments are given in a therapeutically effective amount to the subject. As used herein, the phrase "therapeutically effective amount" means an amount that has any beneficial effect in treating the syndrome (CRS or ARDS), condition, or alveolar membrane injury. Determining the therapeutically effective amount of the active compound of the peptides of the present development may depend on such factors, including but not limited to, the extend to the condition, syndrome or injury to be treated, the age and condition of the subject to be treated, and other factors that may be considered by a prescribing physician. Determining the therapeutic index of the active compounds may be a matter of routine optimization and titration in the art. The term "therapeutic index" or "therapeutic window" refers to the ratio of the dose of a drug or pro-drug that produces a therapeutically beneficial response relative to the does that produces an undesired response, such as death, an elevation of markers that are indicative of toxicity, and/or pharmacological side effects.

[0091] The peptides used and utilized in the methods may be administered to the subject in a pharmaceutically acceptable carrier, adjuvant, or vehicle. Select examples of pharmaceutically acceptable carriers, adjuvants, and vehicles, which are well-known in the art are disclosed in Remington: The Science and Practice of Pharmacy, 2ist Ed.,

Hendrickson, R., et ah, Eds., Lippincott Williams & Wilkins, Baltimore, Md. (2006). The selection of a pharmaceutically acceptable carrier, adjuvant, or vehicle will depend on a variety of factors including but not limited to, the route of administration, dosage levels, the age, weight and/or condition of the subject, etc.

[0092] The pharmaceutical compositions may be adapted for administration by any appropriate route, for example by oral (including buccal and sublingual), nasal, rectal, intratracheal, aerosol, topical, transdermal, parenteral, subcutaneous, intramuscular, intravenous, or intradermal routes. Such compositions may be prepared by any method known in the art of pharmacy, for example, by admixing the active ingredient with carrier(s) or excipient(s) under sterile conditions. Such compositions may also include liposomal compositions as drug carriers.

[0093] In implementations where the pharmaceutical compositions hereof are adapted for nasal, intratracheal, or aerosolized delivery and administration, the carrier may be a solid and may include a coarse powder having a particle size, for example, in the nanometer range up to the micron range. Additionally, particles may range from about 20 to 500 microns and may be administered via rapid inhalation through the nasal passage from a container of the powder that is held close up to the nose. Suitable compositions wherein the carrier is a liquid for administration as nasal spray or nasal drops may include aqueous or oil solutions of the active ingredient.

[0094] In yet another implementation, pharmaceutical compositions may be adapted for inhalation via fine dusts or mists that may be generated by means of various type of metered dose pressurized aerosols, supercritical fluid aerosolization, nebulizers, or insufflators.

[0095] In yet another implementation, pharmaceutical compositions adapted for parenteral administration include aqueous and non-aqueous sterile injection solution which may contain antioxidants, buffers, bacteriostats, and solutes which render the formulation substantially isotonic with the blood of the intended recipient; and aqueous and non-aqueous sterile suspensions which may include suspending agents and thickening agents. Excipients which may be used for injectable solutions include water, alcohol, polyols, glycerin, and vegetable oils, for example. The compositions may be presented in unit-dose or multi-dose containers, for example, in sealed ampoules and vials, and may be stored in freeze-dried (lyophilized) condition requiring only the addition of sterile liquid carrier, for example water for injections, immediately prior to use. Extemporaneous injection solutions and suspensions may be prepared from sterile powders, granules, and tablets. The pharmaceutical compositions may contain preserving agents, solubilizing agents, stabilizing agents, wetting agents, emulsifiers, sweeteners, colorants, odorants, salts (substances of the present developments may themselves be provided in the form of a pharmaceutically acceptable salt), buffers, coating agents, or antioxidants. Salts may include acetate salts, hydrochloride salts, sodium chloride salts, or other salts acceptable and useful for the delivery of the peptide.

[0096] Markers of CRS, ARDS, and alveolar capillary membrane injury may be known in the art and include but are not limited to the presence of inflammatory cytokines. Examples, of inflammatory cytokines may include, but are not limited to, interleukin-1 (IL-1), interferon gamma (IFNy), tumor necrosis factor alpha (TNFa), and interleukin-8 (IL-8). Assaying for specific cytokines may be well known in the art and may include assays such as ELISA assays, Northern blots, Western blots, activity assays, and the like. Other markers of CRS, ARDS, and alveolar capillary membrane injury may include, but are not limited to, changes in blood pressure, increased number of lung neutrophils, increased levels of lung GSSG, increased concentration of expired H202, increased levels of lactate dehydrogenase (LDH) and a lung leak index. Other markers can be assayed using morphological assays of lung injury, physiologic derangements including measurements of hypoxia, and abnormalities of including GSH depletion, alterations of GSH/GSSG ration, increased measurements of oxidative stress, e.g. increased levels of 8-iso-PGFa. IL-6 is also recognized as being associated and indicative of CRS and/or ARDS. Assays for measuring each of the markers of CRS, ARDS, and alveolar capillary membrane injury may be known in the art.

[0097] The following examples are provided for purpose of illustration and are not intended to limit the scope of the present invention.

EXAMPLES Example 1

[0098] FIG. 1, which includes FIG. 1 A to FIG. IE, demonstrates that Th40 cells from TID subjects respond to diabetes self-antigens and are induced to make pro-inflammatory cytokines. Percent of CD4+CD40+ T cells expressing: TNFa (A); IFNy (B); the pro- inflammatory cytokine IL-6 (C); and the anti-inflammatory Th2 cytokine, IL-4 (D). Dashed line represents, background levels of cytokine+ T cells. T cells from TID and control subjects were challenged with PHA, a TCR non-specific mitogen and compared for Thl (IFNy) versus Th2 (IL-4) cytokine production for 18 h. Graphs represent percentage of cells producing each cytokine (E). Data represent an average from T cells of four T1D and four control subjects. For analysis, samples were gated on CD41oCD40+ or CD4hiCD40- and levels of cytokine are reported from each subset. Levels reported are above isotype controls within each subset.

Example 2

[0099] FIG. 2 which includes FIG. 2A and 2B demonstrates that memory phenotype Th40 cells from MS patients produce both IL-17 and IFNy Total blood lymphocytes were stained and gated for CD4 and CD45RO expression to delineate memory cells. (A) Within that population Th40 cells were assayed for IFNy and IL-17 production by intra-cellular staining. Levels of IL-17 and IFNy were determined above isotype controls. Cells were examined immediately ex vivo. (B) Graph represents levels of IFNy only, IL-17 only and IFNy/IL- 17 double positive cells from 11 RRMS subjects. Statistics were done by ANOVA, Tukey comparison, using the Graph Pad Prism program.

Example 3

[00100] FIG. 3 includes sub-parts FIG. 3A, 3B, and 3C. FIG. 3 includes data on MS patients with high Th40 cell levels in peripheral blood express inflammatory cytokines. Purified peripheral blood lymphocytes from MS patients with high (A) or low (B) Th40 cell levels were stained for CD3, CD4, CD40 and intracellularly for different cytokines then analyzed by flow cytometry. Cells were gated on CD4 versus CD40 and CD3 expression was confirmed for Th40 cells then cytokine expression was analyzed within the Th40 population. (C) Graphic representation and statistical analysis. IL-6, IFNy and IL-2 were statistically different between Th40 high and Th40 low (Two- way ANOVA with Sidak's multiple comparisons test).

Example 4

[00101] FIG. 4 provides several graphs showing the cytokine production from lymphocytes in brains of CA/CPR mice. Lymphocytes were isolated from CA/CPR induced mice at 3 hr., 24 hr., 48 hr. and 72 hr. post injury. Cells were stained intracellularly for the Th 1, pro-inflammatory cytokines TNFa and IFNy FIGs. 4A and 4B show cytokines in total CD4+ T cells; FIG. 4C and 4D show cytokines in the Th40 subset of CD4+ cells.

Example 5

[00102] FIG. 5 provides several graphs showing that draining lymph nodes (dLN) lymphocytes from EAE mice secrete high levels of IFNy. dLN were isolated from control (n = 2) and EAE induced mice (10 days post-EAE-induction; n = 3; EAE scores 2, 2, and 0) and lymphocytes purified. Lymphocytes were cultured in the absence/presence of CD3, CD28, and CD40 stimulation for 5 days. Cytokines in the supernatant were assayed. There were significant differences in cytokine production between lymphocytes from EAE and control mice (Two-way ANOVA) as well as between stimulated and isotype treated EAE lymphocytes (two-tailed t-test).

Example 6

[00103] FIG. 6 which includes FIG. 6A and FIG. 6B-1 and 6B-2, demonstrates that T cells from CFA-control challenged mice have a similar cytokine production potential compared to those from CFA+MOG35-55 challenged mice. dLN lymphocytes were purified from CFA-control and CFA+MOG challenged mice, 12 days after challenge, then the cells were cultured in the absence/presence of CD3, CD28, and/or CD40 stimulation or cultured with isotype antibodies for 3 days. Brefeldin A was added the last 2 hours, then the cells were stained for CD3, CD4, CD40, as well as for different cytokines (intracellularly). Cells were gated on CD4+CD40+ (Th40) and CD4+CD40- (Conv. CD4; CD3 expression was confirmed in both populations) then cytokine levels were assessed. Gates were set from isotype controls. (A) Graphs depicting cytokine production by Th40 cells from CFA-control and Th40 cells from CFA+MOG challenged mice. ((B1-B2)) Graphs comparing cytokine production by Th40 cells to cytokine production by conventional CD4 T cells within either CFA-control (left) or CFA+MOG (right) generated cells. Statistical differences in A were calculated by One-Way ANOVA with Bonferroni post-test. Statistical differences in B were calculated by Two-Way ANOVA Example 7

[00104] FIG. 7 shows the cytokine production in Th40 cells. Purified Th40 cells from spleens of 9- to 12-week-old female NOD mice were treated with antiCD3+anti-CD28 (classical T-cell co-stimulus), anti-CD3+ anti-CD40, or isotype controls. Cytokine production was measured after 24 hr. One-way analysis of variance was performed and significant differences are indicated.

Example 8

[00105] FIG. 8 shows CD40 and CD3 induced cytokine phenotypes differ and galectin-9 alters the production level. CD41oCD40+ T cells (Th40 cells) were sorted from 7- 20 weeks old female NOD spleens. Cells were either isotype treated, CD40- or CD3- stimulated in the absence/presence of indicated concentrations of galectin-9 (gal-9; mg/ml) for 3 days then cytokines were measured. Bar graphs depict means with SEM. Asterisks denote significant differences determined by one-way Anova; * - P between 0.01 and 0.05;

** - P ,0.01; *** - P ,0.001. Measurements were done on four individual mice of different ages.

Example 9

[00106] FIG. 9, includes sub-parts 9A, 9B, and 9C, and shows KGYY15 controls the production of inflammatory cytokines by Th40 cells. Immediately ex-vivo lymphocytes from NOD mice treated with KGYY15 (grey) and control mice (black) were stained for cytokines. Data for lymphocytes from (A) peripheral lymph node; (B) pancreatic lymph node; and (C) spleen. Bars show cytokine-positive cells within gated CD4+CD40+ cell populations (Th40), represented as a percentage. Data are from three individual mice from each group and are represented as the mean ± SEM. *p<0.05,

**p<0.01 by two-tailed unpaired t test.

Example 10

[00107] FIG. 10 shows that KGYY6 treatment alters IL-10 production by conventional CD4 T cells. Intracellular cytokine expression profiles were examined in conventional CD4 T cells immediately ex-vivo at the end of the EAE experiment, after 33days. In conventional CD4 T cells from draining lymph nodes (dLN), but not spleen, of KGYY6 treated animals there was an increase in intracellular IL-10 compared to the same cells from untreated animals (p=.0145; t-test).

Example 11

[00108] FIG. 11 shows KGYY6 decreases production of inflammatory cytokines. CD3+CD4+CD40+ (Th40) splenic cells were purified from ApoE-/- with cardiovascular disease. The cells were cultured overnight in the absence/presence of varying concentrations of KGYY6 peptide. Treated cells demonstrated varying degrees of reduction in the inflammatory cytokines IL-2, IFNy and IL-17A compared to the untreated cells.

Example 12

[00109] FIG. 12 which includes sub-parts FIG. 12A and 12B demonstrates that KGYY6 improves glucose tolerance and insulin sensitivity. Graphs represent a statistically significant improvement in glucose tolerance (A; p<0.05) and insulin sensitivity (B; p<0.005). ApoE -/- mice example 13

[00110] FIG. 13 shows ApoE-/- mice treated with KGYY6 decrease production of TGF . Th40 cells were purified from ApoE-/- mice with cardiovascular disease as well as from ApoE-/- mice that were treated with KGYY6. Immediately ex-vivo, the cells were stained for CD3, CD4, and CD40 and intracellular TGF and analyzed by flow cytometry. Cells were gated on CD3 then CD4 and CD40 for Th40 cells then levels of TGF were assessed.

Example 14

[00111] FIG. 14, which includes sub-parts FIG. 14A, 14B, and 14C demonstrates that Dog 15-mer peptide treatment significantly decreases fructoseamine levels in TID dogs. Four longstanding TID domestic dogs were treated with i.v. infusions of dog 15-mer peptide, twice in the first week then weekly thereafter. Levels of fructoseamine were measured before the first infusion and several weeks after initiation of treatment. Example 15

[00112] FIG. 15, which includes sub-parts FIG. 15A and 15B demonstrates that 15- mer peptide used to treat diabetic dogs was able to positively impact and help control blood glucose levels. Dog 15-mer peptide treatment decreases average blood glucose levels in TID dogs. Four longstanding TID domestic dogs were treated with i.v. infusions of dog 15-mer peptide, twice in the first week then weekly thereafter. Levels of blood glucose were measured before the first infusion and several weeks after initiation of treatment. All but one of the 4 dogs achieved better blood glucose control.

Example 16

[00113] FIG. 16 provides graphs of four dogs treated with 15-mer peptide and demonstrates that Dog 15-mer peptide treatment increases c-peptide in TID dogs. Four longstanding TID domestic dogs were treated with i.v. infusions of dog 15-mer peptide, twice in the first week then weekly thereafter. Levels of c-peptide were measured before the first infusion and several weeks after initiation of treatment.

Example 17

[00114] FIG. 17 provides a graph of that demonstrates that KGYY 15 regulates the inflammatory cytokine IFNy without impacting production of non-inflammatory IL-4.

Human T cells, isolated from peripheral blood of TID subjects, were stimulated with autologous antigen presenting cells loaded with human islets in the absence/presence of KGYY15 then intracellular IFNy and IL-4 was measured by flow cytometry. P<0.0001 for IFNy.

[00115] The various features, processes, and implementations described above may be used independently of one another, or may be combined in various ways. All possible combinations and sub-combinations are intended to fall within the scope of this disclosure. In addition, certain method or process blocks may be omitted in some implementations. While certain example implementations have been described, these implementations have been presented by way of example only, and are not intended to limit the scope of the inventions disclosed herein. Thus, nothing in the foregoing description is intended to imply that any particular feature, characteristic, step, module, or block is necessary or indispensable. Indeed, the novel methods and compositions described herein may be embodied in a variety of other forms; furthermore, various omissions, substitutions, and changes in the form of the methods and systems described herein may be made without departing from the spirit of the inventions disclosed herein. The accompanying claims and their equivalents are intended to cover such forms and modifications as would fall within the scope and spirit of certain of the inventions disclosed herein.

REFERENCES

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Protocol Title: Treatment of Cytokine Release Syndrome in COVID-19 Patients [00147] This study will be conducted in compliance with the clinical study protocol (and amendments), the World Medical Association Declaration of Helsinki, International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) Guideline for Good Clinical Practice E6 (R2), applicable US Food and Drug Administration (FDA) regulatory requirements, and local regulations governing the conduct of clinical studies.

[00148] The protocol, informed consent form(s), recruitment materials, and all patient materials will be submitted to the Institutional Review Board (IRB) for review and approval. Approval of both the protocol and the consent form must be obtained before any patient is enrolled. Any amendment to the protocol will require review and approval by the IRB before the changes are implemented to the study. In addition, all changes to the consent form will be RB-approved; a determination will be made regarding whether a new consent needs to be obtained from patients who provided consent, using a previously approved consent form. Abbreviations

Protocol Summary PROTOCOL SYNOPSIS

Table 1 - Schedule of Activities (So A)

1 Vital signs to include temperature, pulse oxygen, respirations, blood pressure, pulse, cardiac rhythm (as per cardiac monitor)

2 Minimum of q2 hours vital signs (blood pressure, oxygen, pulse, respiratory rate and brief nursing assessment).

3 EOI: end of infusion

4 Within 24 hours of First Tx

5 Brief physical exam includes a cardiac, lung, abdominal and extremity exam with examination of IV access site, plus any other examination deemed necessary by the treating providers. Introduction Study Rationale

[00138] One of the identified causes of death in the most severe cases of SARS-CoV-2 infections, or COVID-19, is hypercytokinemia, also known as a cytokine storm. In the most severe cases acute lung injury and acute respiratory distress syndrome (ARDS), are seen; each associated with hypercytokinemia. In addition, multi-organ failure involving heart, liver and kidneys occurs (Huang et al 2020).

[00139] Increased plasma concentrations of the cytokines TNFa, IL-Ib, IL-2, IL-7, G- CSF, GM-CSF, MCP-1, MIP-1 a, and IFNy are being reported in severe COVID-I 9 subjects (Chau et al 2020). T cells that concomitantly produce IFNy and GM-CSF are reported in effected tissues. Th40 cells are a subset of conventional CD4 T cells that express the CD40 receptor. Th40 cells are highly pro-inflammatory, producing each of the cytokines described during hypercytokinemia. Th40 cells transmigrate into various tissues including lung, heart, liver, and brain during trauma including models of infection.

[00140] CD40 is a proven nexus for inflammatory cytokine induction. CD40 engagement with its ligand, CD 154, leads to large scale production of IL-la, IL-Ib, IL-2, IL- 6, IL-17a, IL-21, IL-22, TNFa, GM-CSF and IFNy. CD154 is expressed on T cells, some antigen presenting cells and on platelets, and in soluble form. Research has demonstrated that Th40 cells express pro-inflammatory cytokines that drive auto-inflammation in both type-1 diabetes and multiple sclerosis (Vaitaitis et al 2019; Vaitaitis et al 2017; Vaitaitis et al 2014; Wagner et al 1994; Alderson et al 1993). Moreover, additional research suggests that SARS- like viral particles may induce CD40 expression on dendritic cells (Bai et al 2008). Controlling the CD40/CD154 mediated signals on T cells, but also on monocytes and macrophages, could disrupt hypercytokinemia and tissue migration of culprit cells during an infectious disease like COVID-19. A crucial question is how to inhibit the CD40/CD154 interaction.

[00141] It is proposed that during severe cases of COVID-199, the CD40/CD154 interaction promote hypercytokinemia. The investigational drug, OPT101, is a small peptide derived directly from the CD 154 protein sequence that has proven to be highly successful in controlling the autoimmune diseases type I diabetes and multiple sclerosis (Vaitaitis et al 2014; Vaitaitis et al 2019). These diseases experience elevated levels of inflammatory cytokines including IL-Ib, TNFa, IFNy, GM-CSF and IL-6 (Abrahamian et al 2007; de Souza Bastos et al 2016; Wen et al 2006; Siebert et al 2008). When CD40/CD154 interaction was inhibited by OPT101, inflammatory cytokines were substantially and significantly reduced (Vaitaitis et al 2014). This suggests that controlling CD40/CD154 interaction could control hypercytokinemia in COVID-19 patients.

Nonclinical Toxicology

[00142] In a preliminary toxicity study rats and dogs were given a single dose of OPT 101 as an IV bolus. Rats dosed at 50 or 100 mg/kg by bolus IV injection did not tolerate the treatment due to the mortality of two rats, and adverse clinical signs. When OPT101 was administered to beagle dogs at 50 or 100 mg/kg by bolus IV injection OPTlOlwas not tolerated due to adverse clinical signs, including prostration, slight salivation, decreased activities, purple or red skin colored in the abdomen ventral, lateral ears or conjunctiva(s), lips, or periorbital, soft stool, medium food-like, red/brown, or small and frothy vomitus, increased respiratory rate, and labored breathing. Clinical pathology effects included increases in leukocyte count, erythrocyte and platelet counts. There was a notable increase of prothrombin time (increase 288%) and slight decrease of fibrinogen (down to 32%).

[00143] There were no increases in serum C5b-9 complement levels for either 50 or 100 mg/kg dose levels, suggesting lack of complement activation. There were notable increases of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, g- glutamyltransferase, urea, creatinine, calcium, phosphorus, total bilirubin, and creatine kinase, and a decrease of potassium for one at 50 and 100 mg/kg by IV injection compared with pretest values. These effects were considered to be adverse at 100 mg/kg, however, no liver or kidney lesions were seen at histopathology evaluation

[00144] Due to these adverse effects in the rats and dogs after a bolus IV injection, the administration of OPTlOlwas changed to IV infusion over 30 minutes for the definitive GLP toxicity studies. Rats and dogs were treated once a week for 8-weeks, by 30-minute IV infusions. The PK of OPTlOlwas also determined following the first and last dose in each study. Doses of 10, 100 or 200 mg/kg/dose in rats were well tolerated and did not result in any adverse effects. The no observable adverse effect level (NOAEL) for OPT101 was considered to be the 200 mg/kg level. Doses of 10, 100, or 400 mg/kg/dose in dogs were well tolerated. The only effects observed were infusion reactions in all treated animals. Due to the incidence and severity of the infusion reactions, the clinical signs were considered adverse at 100 and 400 mg/kg, but because of the lower incidence and severity at 10 mg/kg, the effects at the 10 mg/kg were considered non-adverse. Plasma drug levels increased with increasing dose and there was no marked drug accumulation over the 8-week study.

[00145] The clinical signs seen in the rat and dog studies were consistent with a release of histamine and other immune mediators. To test this, rats were given a single bolus IV dose of OPT101 at 12.5 mg/kg of OPT101 The treatment resulted in clinical observation consistent with a histamine reaction, and serum histamine levels were increased significantly 10-minutes post-treatment. At 1- hour post-treatment there was no decreases in serum C3 levels (as measured by conversion to human SC5b-9), suggesting no complement activation, and no changes in serum IFN-g, TNF-a, IL-Ib, IL-4, IL-5, IL-6, IL-10, or IL-13 levels. There was a 1.6-fold increase in serum in one chemokine (KC/GRO (CXCL1).

[00146] Since some of the clinical signs were consistent with a drop in blood pressure, a single dose dog study was done, giving doses of 0.3, 1 or 100 mg/kg by a 30-minute IV infusion, and focused on cardiovascular effects. There was no OPT101 -related body weight, food consumption, body temperature, respiratory rate and coagulation changes. However, the dogs dosed at 100 mg/kg showed significantly elevated serum levels of histamine at 5 and 30 minutes after start of infusion. Apparent histamine related clinical observations included salivation, vomitus, incontinence, discolored skin, swelling and rash at both 1 and 100 mg/kg. The 100 mg/kg group had much more severe clinical observations compared to 1 mg/kg. These effects were associated with decreases in blood pressure and heart rate for the dogs treated with 100 mg/kg. The blood pressure and heart rate returned to normal by 1 hour after end of infusion. There were no clinical observations or physiological changes seen with the 0.3 mg/kg group, so 0.3 mg/kg was considered a no observable effect level (NOEL). [00147] It has been shown that using an anti-CD 154 monoclonal therapeutic approach to interfere with the CD40-CD154 interaction there was efficacy in animal models, but in the clinical trial of one of the monoclonal antibodies there was binding to platelets resulting in emboli. Therefore, the clinical trials were halted (Kawai et al 2000, abstract). To determine if OPT101 has similar effects as the monoclonal antibody, an in vitro study was done with human platelets to determine if OPT101 would affect platelet aggregation, as measured by light transmission aggregometry. Platelet aggregation induced with adenosine diphosphate or collagen were not affected when treated with OPT101 at 0.1, 0.3, 3 or 30 pg/mL. In addition, no spontaneous platelet aggregation was observed in samples treated with OPT101 at 30 pg/mL. Therefore, OPT101 had no impact on human platelet aggregation in vitro. Importantly, there was no evidence of thromboemboli in rats and dogs in the 8-week toxicology studies.

[00148] There was clear difference between the infusion reactions seen in the rats and dogs, and IgE- mediated anaphylaxis or other antigen-dependent hypersensitivity. IgE/antigen-dependent degranulation of mast cells is associated with a sustained release of larger and more heterogeneously shaped granule structures, whereas peptide-activated mast cells rapidly secrete small and relatively spherical granule structures (Gaudenzio 2016). This results in a more sustained, severe response with immunologic IgE-mediated anaphylactic reactions compared to the peptide infusion reaction (Bochner 1990; Lawrence et al 2017; Lu et al 2017). In the animal studies, the clinical signs and release of histamine was very transient. In addition, the infusion reactions were also elicited by a scrambled version of OPT101 (same amino acids but in a different sequence), showing the reaction was not OPT101 -dependent. The non-immunologic infusion reactions have been shown to be mediated by complement activation as well as release of histamine and other mediators (Simons 2014). There was no evidence of complement activation in the animal studies. [00149] Other peptides have been shown to cause infusion reactions. For example, the FDA-approved peptide drug icatibant causes a reaction due to histamine release that is quickly reversed after end of infusion, similar to OPT101(NDA 022150). Except for the infusion reactions, and related effect on clinical pathology, there were no other adverse effects seen in the rat and dog 8-week GLP toxicity studies.

[00150] OPT101 was negative in the standard reverse bacterial mutation assay (Ames assay).

Risk Assessment Anticipated Adverse Events

[00151] Animal toxicity studies have shown transient histamine-induced infusion reactions which may manifest as some of the following: Pyrexia Chills Flushing Hypotension Dyspnea Wheezing Back pain Abdominal pain Urticaria

Benefit Assessment

[00152] There are potential direct benefits to the patient in the study as OPT101 may reduce the hypercytokinemia resulting from the SARS-CoV-2 infection.

Overall Benefit: Risk Conclusion

[00153] Since no approved alternative therapies exist for COVID-19, and COVID-19 has been associated with a high risk of mortality, the probable risk of using the OPT101 Infusion therapy is deemed to be no greater than the probable risk from the disease.

[00154] The concept of risk is generally understood to refer to the combination of the probability and magnitude of some future harm. According to this understanding, risks are considered "high" or "low" depending on whether they are more (or less) likely to occur, and whether the harm is more (or less) serious. This study presents minimal risk as the probability and magnitude of harm or discomfort anticipated in the research are not greater in and of itself than those encountered with the COVID-19 disease. For additional information on risk, see the IB.

Study Design

Rationale for Study Design

[00155] This first-in -human, Phase 1 is non-randomized, open label, sequential ascending dose study in subjects > 18 years old. A total of up to 12 patients will be dosed.

All subjects will receive a total of 8, one per day treatments via a 30-minute slow infusion. For the first cohort (3 subjects), the dose will escalate after 2 days of treatment with 4 escalating doses being administered over the course of treatment (up to 8 days). The planned dose levels are 0.5, 1.0, 2.0 and 4.0 mg/kg. Safety and tolerability, and immunological variables will be assessed at each dose for this cohort, and escalation to the next highest dose will occur only if no DLT is observed. If dose limiting toxicity (DLT) is observed for any dose level, an intermediate dose level between the dose level that exceeds the maximum tolerated dose (MTD) and the previous defined dose level may be used for the remainder of infusions for all patients. Infusion reactions were seen in the nonclinical toxicity studies. All patients will be in ICU-level care, equipped to treat allergic reactions, including continuous vital sign monitoring. MTD is defined as a dose at which less than 33% of subjects have a DLT during the first 2 days of the treatment, regardless if the IP is considered responsible. [00156] Subjects will be initially selected for the study based upon their medical histories and laboratory studies obtained prior to the study, according to the inclusion and exclusion criteria enumerated in the protocol. During the subject recruitment, the investigator will explain the study in detail to the patient or their representative (e.g. power of attorney) and provide a copy of the informed consent to the subject for review. If the patient agrees to participate, the IRB approved consent form will be signed. Each patient will receive a copy of the signed consent form. When consent is obtained from a legally authorized representative, a subject's incapacity to consent will first be verified and documented by two physicians, one of whom will be independent of the study team for patients who are unconscious or have documented diagnosis of delirium. In the case of conscious, non- delirious patients, documentation of incapacity to consent will include evaluation by a psychiatrist or psychologist.

[00157] Once patients are identified and consented, each patient in the first cohort will receive 1 infusion treatment that will be performed with 0.5 mg/kg for 2 days. Patients will receive 1 thirty (30) minute long infusion of peptide therapy daily until the patient is showing signs of improvement with laboratory markers and or improved shortness of breath, fever and cough. If no safety concerns are raised, the patient will receive 1 infusion treatment with 1 mg/kg of peptide daily for an additional 2 days. If no dose limiting toxicity is observed, the dose will be raised again to 2 mg/kg and 4 mg/kg for the remaining 4 days (2 days at each dose). [00158] Safety data from the lower dose will be reviewed by the PI before patients receive the next higher dose. Safety, tolerability, immunological, and clinical effects will be assessed up to the 8 total days of infusion.

[00159] Patients will be followed for safety, immunological, and clinical assessments for 3 days after the last (up to Day 8) treatment. An additional cytokine assessment will be performed the day prior to discharge along with vital signs. Follow up via call or text with all patients will occur at 30 days post last day of treatment if discharge has already occurred. Patients experiencing immunological and/or clinical effects may be followed for longer, until the immunological or clinical variable returns to baseline levels.

[00160] The starting dose of 0.5 mg/kg was calculated from 1/10 the 10 mg/kg NOAEL in the dog toxicity study, converted to the human dose on a mg/m2 basis.

Justification for Use

[00161] COVID-19 viral infection is associated with a high case mortality. Currently, there are no documented specific therapies for COVID-19.

End of Study Definition

[00162] A patient is considered to have completed the study if they have completed all phases of the study as shown in the SoA, Table 1, Study Procedure Frequency and Timing Overview. The end of the study is defined as 3 days after completion of the last treatment. [00163] Patients will participate in the study for up to eight days for active peptide therapy, with last assessments performed 3 days after the last infusion. A 30 day follow up will occur with cytokine panel and vitals performed the day before discharge from the ICU as applicable. If the patient has been discharged prior to the 30 days, a follow up via call or text will be completed.

Study Population 5.4.1 Inclusion Criteria

[00164] Patients are eligible to be included in the study only if all of the following criteria apply:

1. Laboratory confirmation of COVID-19 infection by PCR 2. Demonstration of cytokine release syndrome. Signs of cytokine release syndrome defined as ANY of the following: o serum ferritin concentration > 1000 mcg/L and rising since last 24 h o single ferritin above 2000 mcg/L in patients requiring immediate high flow oxygen device or mechanical ventilation o lymphopenia defined as <800 lymphocytes/microliter) and two of the following extra criteria

• Ferritin > 700 mcg/L and rising since last 24 h

• increased LDH (above 300 IU/L) and rising last 24 h

• D-Dimers > 1000 ng/mL and rising since last 24 h

• CRP above 70 mg/L and rising since last 24 h and absence of bacterial infection

• if three of the above are present at admission, no need to document 24 h rise

3. COVID-19 with the following disease characteristics: i. Early acute lung injury (ALI)/early acute respiratory distress syndrome (ARDS). ii. Severe disease, defined as:

• dyspnea,

• respiratory frequency > 30/min,

• blood oxygen saturation < 93%,

• partial pressure of arterial oxygen to fraction of inspired oxygen ratio of <300, and/or

• lung infiltrates >50%. i. Life-threatening disease, defined as: a. respiratory failure, b. septic shock, and/or c. multiple organ dysfunction or failure.

• Admission to the ICU.

Stable blood pressure not requiring vasopressors initially. • Informed consent from the patient or legal representative using the associated Patient Informed Consent form must be completed.

• Male or female aged 2:18 years on the day of signing informed consent

5.4.2 Exclusion Criteria

[00166] Patients are excluded from the study if any of the following criteria apply:

• Patients with a history of venous and arterial thromboembolic events including, but not limited to, the following: deep venous thrombosis, pulmonary embolism, myocardial infarction, stroke, transient ischemic attack, or arterial insufficiency causing digital gangrene should be excluded. In addition, patients with an already known increase in Von Willebrand Factor or Factor IV as can be seen in COVID-19 infections. Patients with a prior history of abnormal prothrombotic laboratories such as congenital or inherited deficiency of antithrombin III, protein C, protein S, or confirmed diagnosis of antiphospholipid syndrome should also be excluded

• Known pre-existing non-COVID-19 related hypercoagulability or other coagulopathy.

• Patients who are already intubated prior to starting peptide therapy (peptide therapy may be continued if patient is intubated after enrollment)

• Biopsy proven cancer not in remission

• Worsening hemodynamic instability

• History of hypersensitivity to antihistamines

• Is pregnant

• Participation in another competing investigational drug, investigational product or vaccine trial

• Advance directive indicating no desire for heroic measures

• Voluntary refusal of the patient or the designated legal representative

5.5 Enrollment Failures

[00167] A minimal amount of screen failure data will be recorded to ensure transparent reporting of screen failure patients, to meet publishing requirements and to respond to queries from regulatory authorities. The information to be recorded on screen failure patients will include but not be limited to demography, eligibility criteria, and any adverse events.

5.6 Study Intervention

5.7 Study Intervention Compliance

[00168] If there are any deviations from the planned procedures, these will be recorded in the CRF.

5.8 Concomitant Therapy

[00169] For this protocol, a prescription medication is defined as a medication that can be prescribed only by a properly authorized/licensed clinician. Medications to be reported in the eCRF are concomitant prescription medications. Patients will be allowed to remain on their routine medications throughout the active study period unless prohibited in exclusion criteria. Prohibited therapies include:

• Any types of thromboembolic treatment prior to COVID -19 hospitalization

5.9 Patient Discontinuation/Withdrawal

[00170] The patient may withdraw from the study at any time at his/her own request or may be withdrawn at any time at the discretion of the investigator for safety, behavioral, compliance, or administrative reasons. This is expected to be uncommon.

[00171] At the time of discontinuing from the study, if possible, an early discontinuation visit should be conducted, as shown in the SoA. See SoA for data to be collected at the time of study discontinuation and follow-up and for any further evaluations that need to be completed. The patient will be permanently discontinued both from the study intervention and from the study at that time. If a patient withdraws from the study, he/she may request destruction of any samples taken and not tested, and the investigator must document this in the site study records.

5.10 Study Assessments and Procedures

[00172] Study procedures and their timing are summarized in the Schedule of Activities (SoA). Adherence to the study design requirements, including those specified in the SoA, is essential and required for study conduct. All evaluations must be completed and reviewed to confirm that potential patients meet all eligibility criteria.

[00173] A screening log will be maintained to record details of all patients screened and to confirm eligibility or record reasons for screening failure or early termination, as applicable. Procedures conducted as part of the patient's routine clinical management (e.g., blood count) and obtained before signing of the ICF may be utilized for baseline purposes provided the procedures met the protocol-specified criteria and were performed within the time frame defined in the SoA.

5.10.1 Vital Signs

[00174] To be measured and recorded on the treatment log sheet every 5 minutes during treatment or more often if symptoms so indicate. Vital signs will include blood pressure, heart rate, respiratory rate and temperature. If a clinically significant abnormality is found prior to, during or immediately after infusion of OPT101, during the study, and/or at any of the follow-up visits, or if the investigator feels that there has been a clinically significant change from screening/baseline, it should be recorded as an adverse event and the study patient will be followed until the vital sign has normalized or stabilized.

5.11 Safety Assessments

[00175] Planned timepoints for all safety assessments are provided in SoA in Section 3.

5.11.1 Laboratory

[00176] The following laboratory tests will be done during the study:

[00177] Any value outside the normal range will be flagged for the attention of the investigator or designee at the site. The investigator or designee will indicate whether the value is of clinical significance. If the result of any test (or repeat test, if done) from the samples taken during the screening is indicated as clinically significant, the study patient will NOT be allowed into the study without permission of the OP-T LLC Medical Monitor. [00178] Additional testing during the study may be done if medically indicated. If a clinically significant abnormality is found in the samples taken after dosing, during the study, and/or at the follow-up visit, it should be recorded as an adverse event and the study patient will be followed until the test(s) has (have) normalized or stabilized.

5.11.2 Schedule of Assessments

[00179] A detailed schedule of assessments is provided in SoA.

5.11.2.1Before Treatment

[00180] The patient will be assessed for study participation based on the inclusion and exclusion criteria. During this period, study procedures will be explained in detail by study staff, informed consent will be obtained, fully executed with copy provided to the patient or Legally Authorized Representative (LAR). The following activities will be performed:

• Identify appropriate patients via inclusion/exclusion criteria;

• Fully execute informed consent;

• Begin adverse event/concomitant medication monitoring;

• Demographics: race, ethnicity, sex, date of birth;

• Physical exam: noting all abnormal findings • Vital Signs; temperature, pulse oxygen, respiration, blood pressure, pulse, cardiac rhythm (as per cardiac monitor)

• Serum Pregnancy (if applicable);

• Collect blood sample for assessment of baseline levels of COVID-19 virus and baseline labs immediately prior to initiating OPT101 treatment;

• Consequently, the clinical response to any administered medications should be monitored closely to determine if increasing the dose may be warranted;

• Place OPT101 IV for infusion if one is not already in place

• Prepare Investigational product per pharmacy manual

5.12 Study Treatments Administered

[00181] The investigational product, OPT101, will be provided as a sterile solution in 10 mM acetate buffer, in 5% glucose, in water, pH 5.5, 5 mL at 20 mg/mL, 100 mg/vial. On the same day as the investigational product administration, the product will be diluted in saline to a volume of 50 mL to the concentration of OPT101 required for each dose level, and administered by intravenous (IV) infusion over 30 minutes.

[00182] The table below (Table 2) provides an example of dose preparation procedure for all 5 doses to be used in this trial. The dose will be adjusted based on body weight (kg) and is provided below for a subject with a body weight of 70 kg. Calculations and final formulation must be documented on the appropriate case report form (CRF).

Table 2: Example Dosing Preparation Procedure for OPT101 based on bodyweight

5.13 OPT101 Treatment Instructions

[00183] The IP infusion will be conducted unblinded to the dose level, and study staff (not performing any study related procedures) will be unblinded to prepare the IP for infusion. The IP is to remain frozen in -20°C freezer until preparation for infusion. Detailed instructions on the preparation and administration of the drug are provided in the Infusion Dose Preparation Instructions that will be provided by the Sponsor. If infusion reactions are observed anytime during the study for a subject, pre-medication with an antihistamine should occur for that subject prior to additional dosing.

5.14 Treatment Assignment

[00184] Each patient will be assigned a subject ID and will only be identified by this unique ID. If, as an exception, it is necessary for safety or regulatory reasons to identify the subject, all parties will be bound to keep this information confidential. The subject ID will be used for patient identification throughout the study. The numbers will be assigned sequentially. The subject ID should be used on all study documents relating to the subject from screening and throughout the study.

5.15 Dose Modification

[00185] The investigational product will be prepared by an unblinded study staff member and administered by the Investigator or authorized study site staff. All subjects will be given the assigned dose level without dose modification. The 30-minute infusion may be terminated if AE are observed.

5.15.1 Stopping Criteria

5.15.1.1 Dose Escalation Stopping Criteria

[00186] Data for all subjects will be reviewed by the Safety Review Committee (SRC) before dose escalation or de-escalation, or at any time point as needed when safety concerns arise. In addition to the SRC oversight and recommendations, the following stopping criteria will be implemented:

[00187] Subject stopping criteria: If a subject experiences an AE that is deemed by the clinical site Principal Investigator to be at least "possibly" drug-related and is Grade 2:3 in severity (using the Common Terminology Criteria for Adverse Events (CTCAE v 5), that subject will be withdrawn from dosing, return for all scheduled evaluation visits, and be followed until the AE resolves or stabilizes.

[00188] Cohort stopping criteria: If 33% (2 of the first 6 patients), at any time experience any of the following events not clearly due to the underlying disease or extraneous causes and is deemed by the clinical center Principal Investigator to be at least "possibly" drug-related and Grade 2:3 in severity by CTCAE. Dosing in that cohort, as well as further dose escalation, will be suspended within that study arm. Events such as:

• An SAE occurs that is not clearly unrelated to IP

• Any Grade 2: 3 (this may exclude Grade 3 nausea/vomiting or diarrhea for < 72 hours with adequate supportive care, Grade 3 fatigue for > 1 week, Grade 2: 3 uncomplicated electrolyte abnormality that resolves spontaneously or in response to conventional medical intervention, and Grade 2: 3 abnormalities in laboratories within a few standard deviations)

• Increases in Von Willebrand Factor from baseline • Increases in Factor VIII from baseline

• Placement on a ventilator

• Hy's law cases

• Any other event that is deemed by the Investigator or Sponsor to pose an unacceptable risk to subjects as a result of dose escalation

[00189] Grade and severity of AEs will be assessed as defined by the National Cancer Institute - Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0.

5.15.2 Infusion-related Reactions

[00190] Subjects will be monitored for signs and symptoms of infusion-related reactions, including pyrexia, chills, flushing, hypotension, dyspnea, wheezing, back pain, abdominal pain, and urticaria. Interrupt or slow the rate of infusion for mild (Grade 1) or moderate (Grade 2) infusion-related reactions.

[00191] Permanently discontinue OPTlOlfor severe (Grade 3) or life-threatening (Grade 4) infusion-related reactions.

[00192] Treatment recommendations are provided below and may be modified based on local treatment standards and guidelines, as appropriate:

[00193] For Grade I symptoms (Mild reaction; infusion interruption not indicated; intervention not indicated):

• Remain at bedside and monitor subject until recovery from symptoms. The following prophylactic pre-medications are recommended for future infusions: diphenhydramine 50 mg IV (or equivalent) and/or acetaminophen/paracetamol 325 to 1000 mg PO at least 30 minutes before additional investigational product administrations.

[00194] For Grade 2 symptoms ((urticaria or erythema; stable vital signs; moderate reaction requires therapy or infusion interruption but responds promptly to symptomatic treatment (e.g., antihistamines, non-steroidal anti- inflammatory drugs, prophylactic medications indicated for < 24 hours)).

• Treat the subject with diphenhydramine 50 mg IV (or equivalent) and/or acetaminophen/paracetamol 325 to 1000 mg PO; remain at bedside and monitor subject until resolution of symptoms. • For future infusions, the following prophylactic pre-medications are recommended: o Diphenhydramine 50 mg (or equivalent) and/or acetaminophen/paracetamol 325 to 1000 mg should be administered at least 30 minutes before study drug infusions. o If necessary, corticosteroids (up to 25 mg of SoluCortef or equivalent) may be used.

[00195] For Grade 3 or 4 symptoms (hypotension, hypoxia, unstable vitals; severe reaction, Grade 3: prolonged (i.e., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for other clinical sequelae (e.g., renal impairment, pulmonary infiltrates). Life-threatening, Grade 4: pressor or ventilatory support indicated).

• Immediately discontinue infusion of the study drug. Begin an IV infusion of normal saline and treat the subject as follows: Recommend bronchodilators, epinephrine 0.2 to 1 mg of a 1:1000 solution for subcutaneous (SC) administration or 0.1 to 0.25 mg of a 1:10,000 solution injected slowly for IV administration, and/or diphenhydramine 50 mg IV with methylprednisolone 100 mg IV (or equivalent), as needed. Subject should be monitored until the Investigator is comfortable that the symptoms will not recur.

• All study drug will be permanently discontinued. Investigators should follow their institutional guidelines for the treatment of anaphylaxis. Remain at bedside and monitor subject until recovery of the symptoms.

[00196] In case of late-occurring hypersensitivity symptoms (e.g., appearance of a localized or generalized pruritus within 1 week after treatment), symptomatic treatment may be given (e.g., oral antihistamine or corticosteroids).

5.15.3 During Treatment Evaluations

• Continue to monitor adverse event/concomitant medication.

• The entire OPTlOlinfusion treatment will be attended and continuously monitored by a designated care-giver. • The following parameters will be recorded on the treatment log sheet; Vital signs every 5 minutes until the treatment is terminated with one last battery of parameters being recorded just prior to treatment termination.

• Blood samples collected at the time points listed in SOA.

5.15.4 After Treatment

• Collect after treatment blood tests

• Vitals signs

• Concomitant Medications

• Adverse Events

Assessment of Safety 6.1 Adverse Event (AE)

[00197] An AE is any untoward medical occurrence in a subject receiving the study drug and which does not necessarily have a causal relationship with this treatment. For this protocol, the definition of AE also includes worsening of any pre-existing medical condition. An AE can therefore be any unfavorable and unintended or worsening sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of OPT101, whether related to use of the OPT101. Abnormal laboratory findings without clinical significance (based on the Principal Investigator's judgment) should not be recorded as AEs. But laboratory value changes that require therapy or adjustment in prior therapy are considered AEs. From the time the subject signs the informed consent form through the Follow-Up Visit all AEs must be recorded in the subject medical record and AE CRF. [00198] AEs will be assessed according to the CTCAE version 5.0, which has been harmonized to MedDRA (Medical Dictionary for Regulatory Activities) coding. If CTCAE grading does not exist for an AE, the severity of the AE will be graded as mild (1), moderate (2), severe (3), life-threatening (4), or fatal (5). Attribution of AEs will be indicated as follows:

• Definite: The AE is clearly related to the OPT101

• Probably: The AE is likely related to the OPT101

• Possible: The AE may be related to the OPT101 • Unlikely: The AE is doubtfully related to the OPT101

• Unrelated: The AE is clearly NOT related to the OPT101

6.1.1 Serious Adverse Event

[00199] An AE or suspected adverse reaction is considered "serious" if in the opinion of a skilled person it results in any of the following outcomes:

• Death

• Life-threatening adverse event

• A medically significant condition (defined as an event that compromises subject safety or may require medical or surgical intervention to prevent one of the three outcomes above).

• Requires inpatient hospitalization or prolongation of existing hospitalization

• Results in persistent or significant incapacity or substantial disruption to conduct normal life functions

• Results in a congenital anomaly/birth defect.

6.2 Adverse Event by Severity or Intensity

[00200] AE severity will be graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE v5.0) available at ctep.cancer.gov/protocoldevelopment/electronic_applications/ docs/CTCAE_v5_Quick_Refer ence_8.5xl l.pdf. The grading scale is illustrated in Table 3. The severity of the AE should be recorded in the appropriate section of the AE page of the eCRF.

Table 3: Definitions of Adverse Events Severity Based on the Common Terminology Criteria for Adverse Events v5.0 (CTCAE). instrumental ADL refer to preparing meals, shopping for groceries or clothes, using the telephone, managing money, etc.

** Self-care ADL refer to bathing, dressing and undressing, feeding self, using the toilet, taking medications, and not bedridden. ADL=activities of daily living

6.3 Relationship between Adverse Events (AEs) and Investigational Product (IP) [00201] Thecausality of each AE will be assessed and classified. The determination of the relationship (if any) between the AE and the IP will be made using the guidelines in Table 4.

Table 4: Guidelines for Determining the Relationship (if any) Between Adverse Event and the Investigational product

6.4 Physical Examination

[00202] Listing of all physical examination assessment will be provided.

6.5 Vital Signs

[00203] Vital signs will be recorded as standard of care per institutional guidelines to include temperature, pulse oxygen, respiration, blood pressure, pulse, cardiac rhythm (as per cardiac monitor). Change from baseline values will be presented for each post-baseline assessment.

[00204] All vital sign values will be reviewed for clinical significance. Additional vital signs will be obtained when clinically indicated. 6.7 Clinical Laboratory Evaluations (including Coagulation Tests)

[00205] Blood study samples will be collected, processed, and shipped according to the instructions from the site's safety laboratory at the time points indicated in the Schedule of Procedures and Assessments.

6.8 Statistical Considerations

6.8.1 Statistical Analyses

[00206] No formal statistical analyses are planned however the following descriptive statistics will be collected and reported:

6.8.2 Demographic and Baseline Characteristics

[00207] The number of patients included in each study population will be summarized by treatment group and overall. Demographic and other baseline characteristics, including sex, age, age group, race, height, weight, and baseline values will be summarized by treatment group, for the Safety, and ITT populations, using descriptive statistics.

6.8.3 Safety Analyses 6.8.3.1 Adverse Events

[00208] Reported AEs will be summarized by the number of patients reporting the events, as well as by System Organ Class, Preferred Term, severity, seriousness, and relationship to study product. For the summary of AEs by severity, each patient will be counted only once within a System Organ Class or a Preferred Term by using the AEs with the highest intensity within each category for each analysis. For the summary of AEs by relationship to study product, each patient will be counted only once within a System Organ Class or a Preferred Term by using the AEs with the greatest reported relationship within each category. For the summary of AEs by relationship to study product and severity, each patient will be counted only once within a System Organ Class or a Preferred Term by using (1) the greatest reported relationship followed by (2) the highest reported intensity.

[00209] All information pertaining to AEs noted during the study will be listed by patient, detailing verbatim, System Organ Class, Preferred Term, start date, stop date, intensity, outcome, and relationship to study product. The AE onset will also be shown relative (in number of days) to the day of study product administration. SAEs will be tabulated by treatment group, relationship to the test article, and a reference to the occurrence of the SAEs to the relative day of treatment start.

6.8.3.2 Clinical Laboratory

[00210] Descriptive statistics for clinical laboratory values and changes from Baseline at each assessment time point will be presented by treatment group for each clinical laboratory parameter. Shift tables to summarized change from Baseline to post Baseline visits will also be presented (e.g., normal to high and normal to low). Separate listings of all data for all the laboratory parameters will be provided.

6.8.3.3 Prior and concomitant Medications

[00211] Else of medications as described in Section 5.15, prior to and during the treatment period for the safety population will be coded with the World Health Organization (WHO) Drug Dictionary and listed by patient. Summary of medication classes will also be tabulated using counts and percentages in each treatment group.

6.8.3.4 Physical Examinations

[00212] Listings of all physical examination assessments will be provided.

6.8.3.5 Vital Signs

[00213] Descriptive statistics will be presented for data related to vital signs (systolic blood pressure diastolic blood pressure, pulse rate and body temperature, pulse oxygen level). Change from baseline values will be presented for each post-baseline assessment. [00214] Shift tables from baseline to each post-baseline visits and to each timepoint describing shifts to abnormality will be provided as well. Only patients with a baseline result and a result at the specified visit for the parameter will be considered.

[00215] A listing of all vital sign assessments will be provided. In addition, a listing will be provided for each parameter where a patient had at least one abnormal result.

6.9 Consent Procedures and Documentation

[00216] Informed consent is a process that is initiated prior to the individual's agreeing to participate in the study and continues throughout the individual's study participation. Consent forms will be Institutional Review Board (IRB) - approved and the patient will be asked to read and review the document. As part of this procedure, the investigator (or designee) must explain orally and in writing the nature, duration, and purpose of the study, and the action of the investigational product in such a manner that the study patient is aware of the potential risks, inconveniences, or adverse events that may occur. The patient will sign the informed consent document prior to any specific procedures being done for the study.

The investigator will not undertake any investigation specifically required for the clinical study until written consent has been obtained. Patients will have the opportunity to carefully review the written consent form and ask questions prior to signing. The patients should have the opportunity to discuss the study with their family or surrogates or think about it prior to agreeing to participate. Patients must be informed that participation is voluntary and that they may withdraw from the study at any time, without prejudice. A copy of the informed consent document will be given to the patients for their records. The informed consent document must be signed and dated; one copy will be handed to the patient, and the investigator will retain the original as part of the clinical study records. The terms of the consent and when it was obtained must also be documented. The rights and welfare of the patients will be protected by emphasizing to them that the quality of their medical care will not be adversely affected if they decline to participate in this study. If a protocol amendment is required, then the informed consent document may need to be revised to reflect the changes to the protocol. If the informed consent document is revised, it must be reviewed and approved by the responsible IRB and signed by all patients subsequently enrolled in the clinical study as well as those currently enrolled in the clinical study.

6.10 Legalized Authorized Representative (LAR)

[00217] The LAR means an individual or judicial or other body authorized under applicable law to consent on behalf of a prospective patient to the patient's participation in the procedure(s) involved in the research (45 CFR 46.102(c)). The regulations state that "no investigator may involve a human being as a patient in research covered by this policy unless the investigator has obtained the legally effective informed consent of the patient or the patient's legally authorized representative" (45 CFR 46.116).

[00218] The issue as to who can be a LAR is determined by the laws of the jurisdiction in which the research is conducted (e.g., local or state law). Some states have statutes, regulations, or common law that specifically address consent by someone other than the patient for participation in research. Most states have no law specifically addressing the issue of consent in the research context. In these states, law that addresses who is authorized to give consent on behalf of another person to specific medical procedures or generally to medical treatment may be relevant if the research involves those medical procedures or medical treatment. The LAR may be a parent, grandparent, caregiver who has the legal authority to grant consent on behalf of another who has been invited to participate in research. Patients under the age of majority will require parental or other assent.

[00219] When the laws of the jurisdiction in which the research is being conducted provide a reasonable basis for authorizing an individual to consent on behalf of a prospective patient to their participation in the research procedure(s), OHRP would consider such an individual to be a LAR as defined by HHS regulations at 45 CFR 46.102(c). IRBs may wish to consult with legal counsel when deciding who can serve as a LAR for patients of proposed research.

[00220] As a general matter, if an adult lacks capacity to consent, for example, as a result of trauma, mental retardation, some forms of mental illness, or dementia - whether temporary, progressive, or permanent - only a legally authorized representative for that adult can give consent for participation in the research, unless the requirement to obtain informed consent is waived by the IRB in accordance with the requirements at 45 CFR 46.116(c)(d), or in accordance with the provisions for emergency waiver, which are permitted under the authority of the HHS Secretary at 45 CFR 46.101(i). Should the patient regain or develop the capacity to consent, then his or her consent must be obtained for any further research, as the consent of the legally authorized representative is no longer valid.

6.11 Electronic (eCRF) Completion

[00221] Electronic case report forms (eCRFs) will be utilized as the data capture system in this clinical study. Local laboratories will be used in this study. The data will be entered in the eCRF. Data collection processes and procedures will be reviewed and validated to ensure completeness, accuracy, reliability, and consistency. A complete audit trail will be maintained for all data changes. Within form and cross form consistency checks will be used to identify errors or inconsistencies. [00222] This information will be provided to the respective study sites by means of queries. Queries may also be manually generated upon request by the Site Monitor (CRA) or after manual review of eCRFs.

6.12 Study Discontinuation and Closure

[00223] The study may be temporarily suspended or prematurely terminated if there is sufficient reasonable cause. Circumstances that may warrant termination or suspension include, but are not limited to:

• Determination of unexpected, significant, or unacceptable risk to participants

• Demonstration of efficacy that would warrant stopping

• Insufficient compliance to protocol requirements

• Data that are not sufficiently complete and/or evaluable

• Determination that the primary endpoint has been met

• Determination of futility

[00224] Study may resume once concerns about safety, protocol compliance, and data quality are addressed. If conditions or events suggest a possible hazard to patients if the clinical study continues, then the clinical study may be terminated. Conditions that may warrant termination of the clinical study include, but are not limited to:

• discovery of an unexpected, relevant, or unacceptable risk to the patients enrolled in the clinical study;

• failure to enroll patients at the required rate.

6.14 Clinical Monitoring

[00225] The investigator must prepare and maintain adequate and accurate records of all observations and other data pertinent to the clinical study for each study patient. The investigator will make all appropriate safety assessments on an ongoing basis. All aspects of the study will be carefully monitored with respect to GCP and standard operating procedures (SOPs) as frequently as necessary to ensure compliance with the protocol, accurate data collection, and conformance with applicable government regulations.

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[00238] Simons FER, Ardusso LRF, Bilo MB et al. World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis. WAO Journal 2011; 4:13- 37. Figure 1.1 Simons 2014

[00239] Vaitaitis GM, Olmstead MH, Waid DM, Carter JR, Wagner DH, Jr. : A CD40- targeted peptide controls and reverses type 1 diabetes in NOD mice. Diabetologia 2014,

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[00240] Vaitaitis GM, Rihanek M, Alkanani AK, Waid DM, Gottlieb PA, Wagner DH, Type 1 Diabetes TrialNet Study G: Biomarker discovery in pre-Type 1 Diabetes; Th40 cells as a predictive risk factor. J Clin Endocrinol Metab 2019.

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