WO2016109823A1

WO2016109823A1 - Treatment of pediatric growth hormone deficiency with human growth hormone analogues

Info

Publication number: WO2016109823A1
Application number: PCT/US2015/068328
Authority: WO
Inventors: Jeffrey L. Cleland
Original assignee: Amunix Operating Inc
Current assignee: Amunix Pharmaceuticals Inc
Priority date: 2015-01-02
Filing date: 2015-12-31
Publication date: 2016-07-07
Anticipated expiration: 2017-07-02
Also published as: WO2016109823A8

Abstract

The present disclosure provides a pediatric growth hormone deficiency (PGHD) therapy for pediatric subjects. In some embodiments, the therapy comprises administering to the pediatric patient with PGHD a human growth hormone -XTEN (hGH-XTEN) fusion protein in therapeutically effective doses once a month, two-times a month, three-times a month, or four-times a month, wherein the treatment continues for at least about 3 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment. In some embodiments, methods disclosed herein achieve results that are not statistically inferior compared to the height velocity achieved with daily injections of hGH alone over the same period.

Description

TREATMENT OF PEDIATRIC GROWTH HORMONE DEFICIENCY WITH HUMAN GROWTH HORMONE ANALOGUES

BACKGROUND OF THE INVENTION

Human growth hormone (hGH) is naturally secreted from the human anterior pituitary as intermittent pulses lasting from minutes to hours typically occurring during sleep. The rate and extent of hGH secretion decreases with aging and is maximal in puberty in normal healthy well-nourished children. hGH binds to the hGH receptor initiating signaling processes involving the STAT (signal transducer and activator of transcription), the MAPK (mitogen-activated protein kinase) and the PI3K (phosphoinositide-3 kinase) pathways. Insulin-like growth factor-I (IGF-I) gene expression is activated from hGH receptor signaling resulting in secretion of IGF-I into the circulation. IGF-I forms a complex with insulin-like growth factor binding protein-3 (IGFBP-3) and the acid labile subunit (ALS). Both IGFBP-3 and ALS expression are also regulated by hGH receptor activation.

In children with growth hormone deficiency (GHD) resulting from lack of expression or secretion of hGH and not caused by a defect in the hGH receptor, replacement therapy with daily injections of recombinant human growth hormone (rhGH) is often prescribed to facilitate near normal growth and development. New bone is formed at the epiphyses in response to hGH and IGF-I resulting in linear growth until the growth plates fuse after puberty. Daily rhGH administration does not mimic the normal endogenous pulses of hGH in non-GHD children, but does result in significant increases in growth with a typical first year growth rate on treatment of 11 cm/yr. Clinical studies of continuous infusion of rhGH with a pump demonstrated comparable growth velocity and IGF-I levels (e.g., standard deviation scores) to those achieved with daily rhGH injections (J0rgensen et al. J. Clin Endocrinol Metab. 70(6), 1616-23 (1990); Laursen, T. et al. J Clin Endocrinol Metab. 80(8), 2410-8 (1995); Tauber, M. et al. J Clin Endocrinol Metab. 76(5), 1135-9 (1993)). Therefore, continuous, as well as pulsatile, administration of rhGH is efficacious.

The safety of daily rhGH therapy has been studied in both GHD children and adults. In some overweight or obese patients, a trend toward increasing fasting and post-prandial insulin levels has been observed. Although generally well tolerated, daily rhGH therapy may cause mild to moderate headache, arthralgia, nausea, vomiting and injection reactions.

Others have reported on various sustained release GH preparations (Cook DM, et al. 2002. J Clin Endocrinol Metab 87(10):4508-4514; Biller BM, et al. 2011. J Clin Endocrinol Metab 96(6): 1718-1726; Peter F. et al., 2012. J Clin Endocrinol Metab 97(2):400-407; Fares F. et al, 2010. Endocrinology 151(9):4410-4417; Sondergaard E, et al. 2011. J Clin Endocrinol Metab 96(3):681-688; de Schepper J et al. 2011. European Journal of Endocrinology 165(3):401-409; Bidlingmaier M, et al. 2006. J Clin Endocrinol Metab 91(8):2926-2930). However, there remains a need for alternative GH therapeutics, dosages, and treatment regimens.

Currently approved growth hormone drugs comprising recombinant human growth hormone (rhGH) require daily injections and consequently pose considerable challenges to patients with GHD. In addition, analysis of clinical trial data on daily rhGH indicates that daily rhGH results in rapid initial growth that wanes over the first year (as well as subsequent years). VRS-317 (SEQ ID NO: 1, FIG. 1) is a novel fusion protein (M.W. 119 kDa) designed to improve upon currently approved growth hormone drugs and consists of rhGH with amino acid sequences (XTEN) attached at the N- and C-termini. Compositions and methods related to VRS-317 are described in, for example, U.S. Patent No. 8,703,717, U.S. Patent Publication No. 2014-0162949, and WO/2014/164568 (U.S. Patent Application No. 14/771,445), which are incorporated herein by reference in their entirety. In some embodiments, the novel fusion protein designed to improve upon currently approved growth hormone drugs retains the biological activity of VRS-317 and comprises an amino acid sequence having at least about 80%, or alternatively, at least about 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% sequence identity to SEQ ID NO: l .

SUMMARY OF THE INVENTION

The present disclosure provides, in various embodiments, an improved therapeutic regimen for pediatric growth hormone deficiency ("PGHD") therapy in children. In particular, the disclosure provides methods for bolus dose administration of compositions of fusion proteins comprising human growth hormone fused to one or more extended

recombinant polypeptides (XTEN) (the fusion protein hereinafter referred to as "hGH-

XTEN"). Accordingly, in one aspect, the present disclosure provides a method of treating pediatric patients having human PGHD with an hGH-XTEN fusion protein.

In one aspect, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in a pediatric patient by administering to the patient with PGHD a dose of human growth hormone-XTEN (hGH-XTEN) fusion protein. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 90% sequence identity to SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 95% sequence identity to SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH-XTEN fusion protein comprises SEQ ID NO: 1. In one other embodiment, the dose is a bolus dose. In one embodiment, the bolus dose of hGH-XTEN is a bodyweight adjusted bolus dose effective to increase the height of said pediatric patient. In another embodiment, the bolus dose of hGH-XTEN is between about 0.80 mg/kg and about 6.3 mg/kg. In another embodiment, the bolus dose of hGH-XTEN is between about 0.80 mg/kg and about 7.0 mg/kg. In one embodiment, the treatment with the bolus dose of hGH- XTEN continues for at least about 3 months from first administration of the bolus dose. In a preferred embodiment, the pediatric patient's height velocity does not decline during the treatment.

In one embodiment, the treatment with the bolus dose of hGH-XTEN continues for at least about 6 months from first administration. In another embodiment, the treatment with the bolus dose of hGH-XTEN continues for at least about 12 months from first

administration. In another embodiment, the treatment with the bolus dose of hGH-XTEN continues for at least about 18 months from first administration.

In other embodiments, the bolus dose of the hGH-XTEN fusion protein is

administered once a month, two-times a month, three-times a month, or four-times a month. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is administered once a month. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is administered three-times a month. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is administered four-times a month. In a preferred embodiment, the bolus dose of the hGH-XTEN fusion protein is administered every two weeks or semimonthly (two- times a month). In additional embodiments, the bolus dose of hGH-XTEN is administered subcutaneously.

In one embodiment, the treatment with the bolus dose of hGH-XTEN is effective to maintain the pediatric patient's height velocity within at least about 10%, at least about 20%, or at least about 30% of that compared to the height velocity achieved in pediatric patients administered daily injections of human growth hormone (hGH) alone of an equivalent amount, on a molar basis, over a comparable dose period.

In one embodiment, the treatment with the bolus dose of hGH-XTEN is effective to achieve a height velocity equivalent to at least about 7 cm/yr to 12 cm/yr in a pediatric patient. In another embodiment, the treatment with the bolus dose of hGH-XTEN is effective to achieve a height velocity equivalent to at least about 8 cm/yr to 11 cm/yr in a pediatric patient. In another embodiment, the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing with hGH-XTEN fusion protein in the pediatric patient. In another embodiment, the height velocity achieved in the pediatric patient is a first year height velocity. In a preferred embodiment, the treatment with hGH-XTEN fusion protein is effective to achieve at least the same height velocity as that achieved by administering daily injections of hGH alone (i.e., hGH not linked to XTEN or any other protein) over the same time period.

In one embodiment, the amount of hGH-XTEN fusion protein administered is comparable, on a molar basis, to an equivalent amount of an hGH alone and administered to a pediatric patient. In other embodiments, the bolus dose of the hGH-XTEN fusion protein is selected from about 0.8 mg/kg to about 1.5 mg/kg, about 1.8 mg/kg to about 3.2 mg/kg, or about 3.5 mg/kg to about 6.3 mg/kg.

In an additional embodiment, the pediatric patient maintains an increase from baseline serum IGF-I standard deviation score (SDS) of at least 1.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, at least about 30 days, or at least about one month following administration of the hGH-XTEN fusion protein. In another embodiment, the pediatric patient maintains an increase from baseline serum IGF-I standard deviation score (SDS) of at least 1.0 for at least about 14 days, at least about 21 days, or at least about 30 days following administration of the hGH-XTEN fusion protein. In another embodiment, the pediatric patient maintains an increase from baseline serum IGF-I standard deviation score (SDS) of at least 1.0 for at least about 14 days, or at least about 30 days following

administration of the hGH-XTEN fusion protein.

In one embodiment, the pediatric patient has a serum IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 following administration of the hGH-XTEN fusion protein bolus dose. In another embodiment, the pediatric patient has a serum IGF-I SDS that is selected from the group consisting of greater than about -1.5 to about 2.0, greater than about -1.0 to about 2.0, greater than about -0.5 to about 2.0, greater than about 0 to about 2.0, greater than about 0.5 to about 2.0, greater than about 1.0 to about 2.0, and greater than about 1.5 to about 2.0. In another embodiment, the pediatric patient has a serum IGF-I SDS that is selected from the group consisting of greater than about -1.0 to about 2.0, greater than about 0 to about 2.0, and greater than about 1.0 to about 2.0. In another embodiment, the pediatric patient exhibits said serum IGF-I SDS following administration of the bolus dose, wherein the administration of the hGH-XTEN fusion protein is once a month, two-times a month, three-times a month, or four-times a month. In another embodiment, wherein the pediatric patient exhibits said serum IGF-I SDS following administration of the bolus dose, wherein the administration of the hGH-XTEN fusion protein is two-times a month, or once a month. In another embodiment, the pediatric patient exhibits said serum IGF-I SDS following administration of at least a second, or a third, or a fourth bolus dose of the hGH-XTEN fusion protein. In another embodiment, the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, at least about 30 days, or at least about one month following administration of the hGH-XTEN fusion protein. In another embodiment, the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 14 days, at least about 21 days, or at least about 30 days following administration of the hGH-XTEN fusion protein. In another embodiment, the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 14 days, or at least about 30 days following administration of the hGH- XTEN fusion protein. In another embodiment, the serum IGF-I SDS is maintained between about -2.0 and about 2.0 following administration of a first, or a second, or a third, or a fourth bolus dose of the hGH-XTEN fusion protein.

In one embodiment, the bolus dose of the hGH-XTEN fusion protein is selected from the group consisting of about 0.8 mg/kg, about 1.0 mg/kg, about 1.2 mg/kg, about 1.4 mg/kg, about 1.6 mg/kg, about 1.8 mg/kg, about 2.0 mg/kg, about 2.2 mg/kg, about 2.4 mg/kg, about 2.6 mg/kg, about 2.7 mg/kg, about 2.8 mg/kg, about 3 mg/kg, about 3.2 mg/kg, about 3.4 mg/kg, about 3.6 mg/kg, about 3.8 mg/kg, about 4.0 mg/kg, about 4.2 mg/kg, about 4.4 mg/kg, about 4.6 mg/kg, about 4.8 mg/kg, about 5.0 mg/kg, about 5.2 mg/kg, about 5.4 mg/kg, about 5.6 mg/kg, about 5.8 mg/kg, about 6.0 mg/kg, and about 6.3 mg/kg. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is about 0.8 mg/kg to about 2.0 mg/kg. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is about 2.0 mg/kg to about 4.0 mg/kg. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is about 4.0 mg/kg to about 6.0 mg/kg. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is about 0.8 mg/kg to about 1.5 mg/kg. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is about 6.0 mg/kg to about 7.0 mg/kg. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is about 0.8 mg/kg to about 1.5 mg/kg. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is about 1.8 mg/kg to about 3.2 mg/kg. In another embodiment, the bolus dose of the hGH- XTEN fusion protein is about 3.5 mg/kg to about 6.3 mg/kg.

In one embodiment, the hGH-XTEN fusion protein has at least about 91%, or at least about 92%, or at least about 93%, or at least about 94%, or at least about 95%, or at least about 96%), or at least about 97%, or at least about 98%, or at least about 99% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In a preferred embodiment, the hGH-XTEN fusion protein comprises the amino acid sequence of SEQ ID NO: l .

In another aspect, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in a human pediatric patient by administering to the patient with PGHD a dose of human growth hormone-XTEN (hGH-XTEN) fusion protein that is effective to maintain the patient's serum IGF-I standard deviation score (SDS) at a certain level. In one embodiment, the method comprises administering an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In one embodiment, the method comprises administering an amino acid sequence having at least about 95% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In one embodiment, the method comprises administering an amino acid sequence comprising the amino acid sequence of SEQ ID NO: l . In one embodiment, the dose is a therapeutically effective bodyweight adjusted bolus dose. In another embodiment, the bolus dose is effective to maintain the patient's serum IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 for at least 7 days after administration of the bolus dose. In another embodiment, the treatment continues for at least about 3 months from first administration and the pediatric patient's height velocity does not decline during the treatment. In another embodiment, the treatment continues at least about 6 months, at least about 12 months, or at least about 18 months from the first administration of the hGH-XTEN fusion protein. In another embodiment, the height velocity of the pediatric patient is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient. In another

embodiment, the bolus dose of the hGH-XTEN fusion protein is between about 0.8 mg/kg and about 6.3 mg/kg. In another embodiment, said hGH-XTEN fusion protein bolus dose is effective to maintain the patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, at least about 30 days, or at least about one month following administration. In another embodiment, the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 14 days, at least about 21 days, or at least about 30 days following administration of the hGH-XTEN fusion protein. In another embodiment, the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 14 days, or at least about 30 days following administration of the hGH- XTEN fusion protein.

In one additional aspect, the present disclosure provides a pediatric bolus dose of an hGH-XTEN fusion protein. In one embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 95% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In one embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence comprising the amino acid sequence of SEQ ID NO: 1. In another embodiment, the hGH-XTEN fusion protein bolus dose is a therapeutically effective bodyweight adjusted bolus dose comprising between about 0.8 mg/kg and about 6.3 mg/kg of hGH-XTEN fusion protein. In another embodiment, the bolus dose is for use in treating human pediatric growth hormone deficiency (PGHD) in a pediatric patient in need. In another embodiment, the treatment continues for at least about 3 months from first administration and the pediatric patient's height velocity does not decline during the treatment. In another embodiment, the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH-XTEN fusion protein. In another embodiment, the height velocity is achieved in the pediatric patient after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient. In another

embodiment, the hGH-XTEN fusion protein comprises the amino acid sequence of SEQ ID NO: 1. In one embodiment, the bolus dose of hGH-XTEN formulated for subcutaneous administration.

In one embodiment, the present disclosure provides for an hGH-XTEN fusion protein for use in a method for the treatment of human pediatric growth hormone deficiency (PGHD) in a human pediatric patient. In one embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 95% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In another

embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence comprising the amino acid sequence of SEQ ID NO: 1. In another embodiment, method comprises administering a bodyweight adjusted bolus dose of the hGH-XTEN fusion protein at a dose between about 0.8 mg/kg and about 6.3 mg/kg effective to increase the height of said pediatric patient. In one embodiment, the treatment continues for at least about 3 months from first administration and the pediatric patient's height velocity does not decline during the treatment. In another embodiment, the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH- XTEN fusion protein. In another embodiment, the height velocity is achieved in the pediatric patient after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing of the hGH-XTEN fusion protein in the pediatric patient. In another embodiment, the bolus dose is administered once a month, two-times a month, three- times a month, or four-times a month. In another embodiment, the bolus dose is administered semimonthly, or monthly. In a preferred embodiment, the hGH-XTEN fusion protein comprises the amino acid sequence of SEQ ID NO: 1. In a preferred embodiment, the bolus dose is administered subcutaneously. In another embodiment, the human pediatric patient has a serum IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 following administration of the bolus dose. In another embodiment, the IGF-I SDS is selected from the group consisting of greater than about -1.5, greater than about -1.0, greater than about -0.5, greater than about 0, greater than about 0.5, greater than about 1.0, and greater than about 1.5. In another embodiment, the IGF-I SDS is selected from the group consisting of greater than about -1.0, greater than about 0, and greater than about 1.0. In another embodiment, the administration is once a month, two-times a month, three-times a month, or four-times a month. In another embodiment, the administration is once a month, or two-times a month. In one embodiment, the present disclosure provides for the use of an hGH-XTEN fusion protein in the manufacture of a medicament for the treatment of PGHD in a pediatric patient. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 95% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH- XTEN fusion protein comprises an amino acid sequence comprising the amino acid sequence of SEQ ID NO: 1. In another embodiment, the hGH-XTEN fusion protein is administered to the pediatric patient as a bodyweight adjusted bolus dose of the hGH-XTEN fusion protein at a dose between about 0.8 mg/kg and about 6.3 mg/kg effective to increase the height of said pediatric patient. In another embodiment, the treatment continues for at least about 3 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment. In another embodiment, the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH-XTEN fusion protein. In another embodiment, the height velocity is achieved in the pediatric patient after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient. In another

embodiment, the bolus dose is administered once a month, two-times a month, three-times a month, or four-times a month. In another embodiment, the bolus dose is administered semimonthly, or monthly. In a preferred embodiment, the hGH-XTEN fusion protein comprises the amino acid sequence of SEQ ID NO: 1. In a preferred embodiment, the bolus dose is administered subcutaneously. In another embodiment, the human pediatric patient has a serum IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 following administration of the bolus dose. In another embodiment, the IGF-I SDS is selected from the group consisting of greater than about -1.5, greater than about -1.0, greater than about -0.5, greater than about 0, greater than about 0.5, greater than about 1.0, and greater than about 1.5. In another embodiment, the IGF-I SDS is selected from the group consisting of greater than about -1.0, greater than about 0, and greater than about 1.0. In another embodiment, the administration is once a month, two-times a month, three-times a month, or four-times a month. In another embodiment, the administration is once a month, or two-times a month.

In another aspect, the present disclosure provides a kit for the treatment of pediatric growth hormone deficiency (PGHD). In one embodiment, the kit comprises a a container which holds a pharmaceutical composition comprising a human growth hormone- XTEN (hGH-XTEN) fusion protein. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH- XTEN fusion protein comprises an amino acid sequence having at least about 95% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence comprising the amino acid sequence of SEQ ID NO: 1. In one other embodiment, the kit comprises a package insert associated with said container, wherein the package insert indicates that said composition is for the treatment of pediatric growth hormone deficiency (PGHD) in a pediatric patient by administration of an initial dose of the hGH-XTEN fusion protein between about 0.8 mg/kg and about 6.3 mg/kg effective to increase the height of said pediatric patient, wherein the treatment continues for at least about 3 months from first administration. In another embodiment, the package insert further indicates administration of a plurality of subsequent doses of the hGH-XTEN fusion protein between about 0.8 mg/kg and about 6.3 mg/kg, wherein the doses are administered once a month, two-times a month, three-times a month, or four-times a month, and wherein the pediatric patient's height velocity does not decline during the treatment. In another embodiment, the administration is once a month, or two-times a month. In another embodiment, the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH-XTEN fusion protein. In another embodiment, the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient. In another embodiment, the container further comprises a pharmaceutically acceptable carrier.

In another aspect, the present disclosure provides a human growth hormone-XTEN

(hGH-XTEN) fusion protein for use in a pharmaceutical regimen for treatment of a treatment of pediatric growth hormone deficiency (PGHD) in a pediatric patient. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 95% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned. In another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence comprising the amino acid sequence of SEQ ID NO: l . In another embodiment, the pharmaceutical regimen comprises administering a bolus dose of the hGH-XTEN fusion protein to treat the pediatric patient, wherein the treatment continues for at least about 3 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment. In another embodiment, the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH-XTEN fusion protein. In another embodiment, the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient. In another embodiment, the pharmaceutical regimen further comprises the step of determining the amount of hGH-XTEN fusion protein needed to achieve an IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 in the pediatric patient. In another embodiment, the pharmaceutical regimen for treating the pediatric patient comprises administering the hGH- XTEN fusion protein in an initial bolus dose between about 0.8 mg/kg and about 6.3 mg/kg and a plurality of subsequent bolus doses of the hGH-XTEN fusion protein between about 0.8 mg/kg and about 6.3 mg/kg. In another embodiment, the bolus doses are administered once a month, two-times a month, three-times a month, or four-times a month. In another embodiment, the bolus doses are administered once a month, or two-times a month.

In a preferred embodiment, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in a pediatric patient, the treatment comprising administering to the pediatric patient with PGHD a human growth hormone- XTEN (hGH-XTEN) fusion protein comprising the amino acid sequence of SEQ ID NO: 1, as a bodyweight adjusted bolus dose administered once a month at about 5.0 mg/kg effective to increase the height of said pediatric patient, wherein the treatment continues for at least 12 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

In another preferred embodiment, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in a pediatric patient, the treatment comprising administering to the pediatric patient with PGHD a human growth hormone- XTEN (hGH-XTEN) fusion protein comprising the amino acid sequence of SEQ ID NO: 1, as a bodyweight adjusted bolus dose administered two-times a month at about 2.5 mg/kg effective to increase the height of said pediatric patient, wherein the treatment continues for at least 12 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

In another preferred embodiment, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in a pediatric patient, the treatment comprising administering to the pediatric patient with PGHD a human growth hormone- XTEN (hGH-XTEN) fusion protein comprising the amino acid sequence of SEQ ID NO: 1, as a bodyweight adjusted bolus dose administered two-times a month at about 3.5 mg/kg effective to increase the height of said pediatric patient, wherein the treatment continues for at least 12 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

In another preferred embodiment, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in a pediatric patient, the treatment comprising administering to the pediatric patient with PGHD a human growth hormone- XTEN (hGH-XTEN) fusion protein comprising the amino acid sequence of SEQ ID NO: 1, as a bodyweight adjusted bolus dose administered two-times a month at about 3.5 mg/kg effective to increase the height of said pediatric patient, wherein the treatment continues for at least 18 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

In another embodiment, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in a pediatric patient, the treatment comprising administering to the pediatric patient with PGHD a human growth hormone-XTEN (hGH- XTEN) fusion protein comprising an amino acid sequence having at least about 90%, or at least 95%, or at least 99% sequence identity to the sequence of SEQ ID NO: 1, when optimally aligned, or comprises the sequence of SEQ ID NO: 1, as a bodyweight adjusted bolus dose between about 0.80 mg/kg and about 6.3 mg/kg, or from at least about 0.8 mg/kg to at least about 1.5 mg/kg, or at least about 1.8 mg/kg to at least about 3.2 mg/kg, or at least about 3.5 mg/kg to at least about 6.3 mg/kg, wherein the bolus dose is administered once a month, two-times a month, three-times a month, or four-times a month, wherein the treatment is effective to increase the height of said pediatric patient, wherein the treatment continues for at least about 3 months from first administration, or at least about 6 months from first administration, or at least about 12 months from first administration, or at least about 18 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment. In the foregoing embodiment, the pediatric patient has a serum IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 following

administration of the hGH-XTEN fusion protein and during the treatment. INCORPORATION BY REFERENCE

All publications, patents, and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication, patent, or patent application was specifically and individually indicated to be incorporated by reference.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 provides the amino acid sequence for VRS-317, an hGH-XTEN fusion protein (hGH sequence is underlined and bold) (SEQ ID NO: 1).

FIG. 2 provides a table summarizing the demographics of Phase 2a trial participants. Age, height SDS and GH stimulation test must be comparable for evaluating relative to other pediatric GHD clinical trials. The Phase 2a and Extension Studies generally consisted of prepubertal children with moderate GHD, representative of the typical U.S. GHD patient population.

FIG. 3 provides a table summarizing the safety profile of VRS-317 over 6 months in patients enrolled in the Extension Study. The safety/tolerability profile of VRS-317 was found to be comparable to daily rhGH; all related AEs are mild (Grade 1) and transient, no related SAEs, no unexpected AEs, no lipoatrophy, and no nodules were associated with extended VRS-317 treatment over 12 months. The number of AEs decreased from the first to the second 6 months of treatment. A few AEs were observed at the 3.5 mg/kg semi-monthly dose.

FIG. 4 provides the IGF-I response to single dose VRS-317 from the Phase lb Study. The top graph shows the maximum IGF-I SDS achieved at various single doses of VRS-317, indicating no overexposure, and the bottom graph shows the increase in average IGF-I SDS between 0-30 days achieved at various single doses of VRS-317. After identifying a preferred single dose and showing that VRS-317 treatment at the concentrations tested does not result in IGF-I overexposure, these results were used to establish a PK/PD model for VRS-317 dosing at different intervals and concentrations.

FIG. 5 provides more detailed IGF-I response analyses from patients enrolled in the Phase 2a Study. The PK/PD model indicated that a change in VRS-317 treatment from 2.5 mg/kg semi-monthly to 3.5 mg/kg semi-monthly would increase average IGF-I SDS into the upper half of the normal range. Therefore, patients dosed at 1.15 mg/kg weekly in the Phase 2a Study were switched on their next visit in the Extension Study to 3.5 mg/kg semi-monthly. FIG. 6 shows the expected dose response increase in IGF-I SDS achieved by changing VRS-317 treatment from 2.5 mg/kg semi-monthly to 3.5 mg/kg semi-monthly, a change predicted from the PK/PD model for VRS-317.

FIG. 7 provides a graph of IGF-I SDS levels over several months of daily rhGH treatment of a patient population having very similar demographics compared to the patients enrolled in the 13VR3 Study and shows that a "conventional" dose of daily rhGH of 40 μg/kg/day yields a comparable IGF-I SDS to 3.5 mg/kg VRS-317.

FIG. 8 shows the dose response of daily rhGH, indicating based on the growth rates of patients treated with different concentrations of daily rhGH that the VRS-317 height velocity results observed correlate to a daily rhGH dose of -30 μg/kg.

FIG. 9 shows the dose response increase in annualized height velocity in the patients that were previously dosed at 1.15 mg/kg weekly in the Phase 2a Study and were later switched on their next visit in the Extension Study to 3.5 mg/kg semi-monthly.

FIG. 10 provides the annualized height velocities measured after 12 months of continuous VRS-317 therapy monthly at 5 mg/kg or semi-monthly at 2.5 mg/kg compared to publicly available source data on daily rhGH treatment at 34 μg/kg/day. These results indicate that whereas VRS-317 provides consistent rate of growth throughout the first year, daily rhGH results in rapid initial growth that wanes over the first year.

FIG. 11 summarizes a 12 month randomized pediatric Phase 3 Study of VRS-317 administered at 3.5 mg/kg semi-monthly as compared to daily rhGH treatment at 34 μg/kg/day, based on results from Phase lb, Phase 2a, and Extension Studies on VRS-317 safety and efficacy.

FIG. 12 summarizes the extension study through 18 months of treatment with somavaratan (VRS-317) dosed at various intervals.

FIG. 13 shows the pharmacodynamics response to increased somavaratan dose

(n=17).

FIG. 14 illustrates mean height velocity (HV±SD) before and after somavaratan dose increase.

DESCRIPTION OF THE INVENTION

Before the embodiments of the invention are described, it is to be understood that such embodiments are provided by way of example only, and that various alternatives to the embodiments of the invention described herein may be employed in practicing the invention. Numerous variations, changes, and substitutions will now occur to those skilled in the art without departing from the invention. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described below. In case of conflict, the patent specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and not intended to be limiting. Numerous variations, changes, and substitutions will now occur to those skilled in the art without departing from the invention.

DEFINITIONS

As used herein, the following terms have the meanings ascribed to them unless specified otherwise.

As used in the specification and claims, the singular forms "a", "an" and "the" include plural references unless the context clearly dictates otherwise. For example, the term "a cell" includes a plurality of cells, including mixtures thereof.

The terms "polypeptide", "peptide", and "protein" are used interchangeably herein to refer to polymers of amino acids of any length. The polymer may be linear or branched, it may comprise modified amino acids, and it may be interrupted by non amino acids. The terms also encompass an amino acid polymer that has been modified, for example, by disulfide bond formation, glycosylation, lipidation, acetylation, phosphorylation, or any other manipulation, such as conjugation with a labeling component.

As used herein the term "amino acid" refers to either natural and/or unnatural or synthetic amino acids, including but not limited to glycine and both the D or L optical isomers, and amino acid analogs and peptidomimetics. Standard single or three letter codes are used to designate amino acids.

The term "natural L-amino acid" means the L optical isomer forms of glycine (G), proline (P), alanine (A), valine (V), leucine (L), isoleucine (I), methionine (M), cysteine (C), phenylalanine (F), tyrosine (Y), tryptophan (W), histidine (H), lysine (K), arginine (R), glutamine (Q), asparagine (N), glutamic acid (E), aspartic acid (D), serine (S), and threonine (T).

The term "non-naturally occurring," as applied to sequences and as used herein, means polypeptide or polynucleotide sequences that do not have a counterpart to, are not complementary to, or do not have a high degree of homology with a wild-type or naturally- occurring sequence found in a mammal. For example, a non-naturally occurring polypeptide or fragment may share no more than 99%, 98%, 95%, 90%, 80%, 70%, 60%, 50% or even less amino acid sequence identity as compared to a natural sequence when suitably aligned.

The terms "hydrophilic" and "hydrophobic" refer to the degree of affinity that a substance has with water. A hydrophilic substance has a strong affinity for water, tending to dissolve in, mix with, or be wetted by water, while a hydrophobic substance substantially lacks affinity for water, tending to repel and not absorb water and tending not to dissolve in or mix with or be wetted by water. Amino acids can be characterized based on their hydrophobicity. A number of scales have been developed. An example is a scale developed by Levitt, M, et al., J Mol Biol (1976) 104:59, which is listed in Hopp, TP, et al., Proc Natl Acad Sci U S A (1981) 78:3824. Examples of "hydrophilic amino acids" are arginine, lysine, threonine, alanine, asparagine, and glutamine. Of particular interest are the hydrophilic amino acids aspartate, glutamate, and serine, and glycine. Examples of

"hydrophobic amino acids" are tryptophan, tyrosine, phenylalanine, methionine, leucine, isoleucine, and valine.

A "fragment" is a truncated form of a native biologically active protein that retains at least a portion of the therapeutic and/or biological activity. A "variant" is a protein with sequence homology to the native biologically active protein that retains at least a portion of the therapeutic and/or biological activity of the biologically active protein. For example, a variant protein may share at least 70%, 75%, 80%, 85%, 90%, 95%, 96%, 97%, 98% or 99% amino acid sequence identity with the reference biologically active protein. As used herein, the term "biologically active protein moiety" includes proteins modified deliberately, as for example, by site directed mutagenesis, insertions, or accidentally through mutations.

A "host cell" includes an individual cell or cell culture which can be or has been a recipient for the subject vectors. Host cells include progeny of a single host cell. The progeny may not necessarily be completely identical (in morphology or in genomic of total DNA complement) to the original parent cell due to natural, accidental, or deliberate mutation. A host cell includes cells transfected in vivo with a vector described herein.

"Isolated," when used to describe the various polypeptides disclosed herein, means polypeptide that has been identified and separated and/or recovered from a component of its natural environment. Contaminant components of its natural environment are materials that would typically interfere with diagnostic or therapeutic uses for the polypeptide, and may include enzymes, hormones, and other proteinaceous or non-proteinaceous solutes. As is apparent to those of skill in the art, a non-naturally occurring polynucleotide, peptide, polypeptide, protein, antibody, or fragments thereof, does not require "isolation" to distinguish it from its naturally occurring counterpart. In addition, a "concentrated", "separated" or "diluted" polynucleotide, peptide, polypeptide, protein, antibody, or fragments thereof, is distinguishable from its naturally occurring counterpart in that the concentration or number of molecules per volume is generally greater than that of its naturally occurring counterpart. In general, a polypeptide made by recombinant means and expressed in a host cell is considered to be "isolated."

An "isolated" polynucleotide or polypeptide-encoding nucleic acid or other polypeptide-encoding nucleic acid is a nucleic acid molecule that is identified and separated from at least one contaminant nucleic acid molecule with which it is ordinarily associated in the natural source of the polypeptide-encoding nucleic acid. An isolated polypeptide- encoding nucleic acid molecule is other than in the form or setting in which it is found in nature. Isolated polypeptide-encoding nucleic acid molecules therefore are distinguished from the specific polypeptide-encoding nucleic acid molecule as it exists in natural cells. However, an isolated polypeptide-encoding nucleic acid molecule includes polypeptide- encoding nucleic acid molecules contained in cells that ordinarily express the polypeptide where, for example, the nucleic acid molecule is in a chromosomal or extra-chromosomal location different from that of natural cells.

A "chimeric" protein contains at least one fusion polypeptide comprising regions in a different position in the sequence than that which occurs in nature. The regions may normally exist in separate proteins and are brought together in the fusion polypeptide; or they may normally exist in the same protein but are placed in a new arrangement in the fusion polypeptide. A chimeric protein may be created, for example, by chemical synthesis, or by creating and translating a polynucleotide in which the peptide regions are encoded in the desired relationship.

"Conjugated", "linked," "fused," and "fusion" are used interchangeably herein. These terms refer to the joining together of two or more chemical elements or components, by whatever means including chemical conjugation or recombinant means. For example, a promoter or enhancer is operably linked to a coding sequence if it affects the transcription of the sequence. Generally, "operably linked" means that the DNA sequences being linked are contiguous, and in reading phase or in-frame. An "in-frame fusion" refers to the joining of two or more open reading frames (ORFs) to form a continuous longer ORF, in a manner that maintains the correct reading frame of the original ORFs. Thus, the resulting recombinant fusion protein is a single protein containing two or more segments that correspond to polypeptides encoded by the original ORFs (which segments are not normally so joined in nature).

In the context of polypeptides, a "linear sequence" or a "sequence" is an order of amino acids in a polypeptide in an amino to carboxyl terminus direction in which residues that neighbor each other in the sequence are contiguous in the primary structure of the polypeptide. A "partial sequence" is a linear sequence of part of a polypeptide that is known to comprise additional residues in one or both directions.

"Heterologous" means derived from a genotypically distinct entity from the rest of the entity to which it is being compared. For example, a glycine rich sequence removed from its native coding sequence and operatively linked to a coding sequence other than the native sequence is a heterologous glycine rich sequence. The term "heterologous" as applied to a polynucleotide, a polypeptide, means that the polynucleotide or polypeptide is derived from a genotypically distinct entity from that of the rest of the entity to which it is being compared.

The terms "polynucleotides", "nucleic acids", "nucleotides" and "oligonucleotides" are used interchangeably. They refer to a polymeric form of nucleotides of any length, either deoxyribonucleotides or ribonucleotides, or analogs thereof. Polynucleotides may have any three-dimensional structure, and may perform any function, known or unknown. The following are non-limiting examples of polynucleotides: coding or non-coding regions of a gene or gene fragment, loci (locus) defined from linkage analysis, exons, introns, messenger RNA (mRNA), transfer RNA, ribosomal RNA, ribozymes, cDNA, recombinant

polynucleotides, branched polynucleotides, plasmids, vectors, isolated DNA of any sequence, isolated RNA of any sequence, nucleic acid probes, and primers. A polynucleotide may comprise modified nucleotides, such as methylated nucleotides and nucleotide analogs. If present, modifications to the nucleotide structure may be imparted before or after assembly of the polymer. The sequence of nucleotides may be interrupted by non-nucleotide components. A polynucleotide may be further modified after polymerization, such as by conjugation with a labeling component.

The term "complement of a polynucleotide" denotes a polynucleotide molecule having a complementary base sequence and reverse orientation as compared to a reference sequence, such that it could hybridize with a reference sequence with complete fidelity.

"Recombinant" as applied to a polynucleotide means that the polynucleotide is the product of various combinations of in vitro cloning, restriction and/or ligation steps, and other procedures that result in a construct that can potentially be expressed in a host cell. The terms "gene" or "gene fragment" are used interchangeably herein. They refer to a polynucleotide containing at least one open reading frame that is capable of encoding a particular protein after being transcribed and translated. A gene or gene fragment may be genomic or cDNA, as long as the polynucleotide contains at least one open reading frame, which may cover the entire coding region or a segment thereof. A "fusion gene" is a gene composed of at least two heterologous polynucleotides that are linked together.

"Homology" or "homologous" refers to sequence similarity or interchangeability between two or more polynucleotide sequences or two or more polypeptide sequences. When using a program such as BestFit to determine sequence identity, similarity or homology between two different amino acid sequences, the default settings may be used, or an appropriate scoring matrix, such as blosum45 or blosum80, may be selected to optimize identity, similarity or homology scores. Preferably, polynucleotides that are homologous are those which hybridize under stringent conditions as defined herein and have at least 70%, preferably at least 80%, more preferably at least 90%, more preferably 95%, more preferably 97%), more preferably 98%, and even more preferably 99% sequence identity to those sequences.

"Ligation" refers to the process of forming phosphodiester bonds between two nucleic acid fragments or genes, linking them together. To ligate the DNA fragments or genes together, the ends of the DNA must be compatible with each other. In some cases, the ends will be directly compatible after endonuclease digestion. However, it may be necessary to first convert the staggered ends commonly produced after endonuclease digestion to blunt ends to make them compatible for ligation.

The terms "stringent conditions" or "stringent hybridization conditions" includes reference to conditions under which a polynucleotide will hybridize to its target sequence, to a detectably greater degree than other sequences (e.g., at least 2-fold over background).

Generally, stringency of hybridization is expressed, in part, with reference to the temperature and salt concentration under which the wash step is carried out. Typically, stringent conditions will be those in which the salt concentration is less than about 1.5 M Na ion, typically about 0.01 to 1.0 M Na ion concentration (or other salts) at pH 7.0 to 8.3 and the temperature is at least about 30°C for short polynucleotides (e.g., 10 to 50 nucleotides) and at least about 60°C for long polynucleotides (e.g., greater than 50 nucleotides)— for example, "stringent conditions" can include hybridization in 50% formamide, 1 M NaCl, 1% SDS at 37°C, and three washes for 15 min each in O. l xSSC/1% SDS at 60°C to 65°C. Alternatively, temperatures of about 65°C, 60°C, 55°C, or 42°C may be used. SSC concentration may be varied from about 0.1 to 2^χ SSC, with SDS being present at about 0.1%. Such wash temperatures are typically selected to be about 5°C to 20°C lower than the thermal melting point for the specific sequence at a defined ionic strength and pH. The Tm is the temperature (under defined ionic strength and pH) at which 50% of the target sequence hybridizes to a perfectly matched probe. An equation for calculating Tm and conditions for nucleic acid hybridization are well known and can be found in Sambrook, J. et al. (1989) Molecular Cloning: A Laboratory Manual , 2nd ed., vol. 1-3, Cold Spring Harbor Press, Plainview N. Y.; specifically see volume 2 and chapter 9. Typically, blocking reagents are used to block nonspecific hybridization. Such blocking reagents include, for instance, sheared and denatured salmon sperm DNA at about 100-200 μg/ml. Organic solvent, such as formamide at a concentration of about 35-50% v/v, may also be used under particular circumstances, such as for RNA:DNA hybridizations. Useful variations on these wash conditions will be readily apparent to those of ordinary skill in the art.

The terms "percent identity" and "% identity," as applied to polynucleotide sequences, refer to the percentage of residue matches between at least two polynucleotide sequences aligned using a standardized algorithm. Such an algorithm may insert, in a standardized and reproducible way, gaps in the sequences being compared in order to optimize alignment between two sequences, and therefore achieve a more meaningful comparison of the two sequences. Percent identity may be measured over the length of an entire defined polynucleotide sequence, or may be measured over a shorter length, for example, over the length of a fragment taken from a larger, defined polynucleotide sequence, for instance, a fragment of at least 45, at least 60, at least 90, at least 120, at least 150, at least 210 or at least 450 contiguous residues. Such lengths are exemplary only, and it is understood that any fragment length supported by the sequences shown herein, in the tables, figures or Sequence Listing, may be used to describe a length over which percentage identity may be measured.

"Percent (%) amino acid sequence identity," with respect to the polypeptide sequences identified herein, is defined as the percentage of amino acid residues in a query sequence that are identical with the amino acid residues of a second, reference polypeptide sequence or a portion thereof, after aligning the sequences and introducing gaps, if necessary, to achieve the maximum percent sequence identity, and not considering any conservative substitutions as part of the sequence identity. Alignment for purposes of determining percent amino acid sequence identity can be achieved in various ways that are within the skill in the art, for instance, using publicly available computer software such as BLAST, BLAST-2, ALIGN or Megalign (DNASTAR) software. Those skilled in the art can determine appropriate parameters for measuring alignment, including any algorithms needed to achieve maximal alignment over the full length of the sequences being compared. Percent identity may be measured over the length of an entire defined polypeptide sequence, or may be measured over a shorter length, for example, over the length of a fragment taken from a larger, defined polypeptide sequence, for instance, a fragment of at least 15, at least 20, at least 30, at least 40, at least 50, at least 70 or at least 150 contiguous residues. Such lengths are exemplary only, and it is understood that any fragment length supported by the sequences shown herein, in the tables, figures or Sequence Listing, may be used to describe a length over which percentage identity may be measured.

The term "non-repetitiveness" as used herein in the context of a polypeptide refers to a lack or limited degree of internal homology in a peptide or polypeptide sequence. The term "substantially non-repetitive" can mean, for example, that there are few or no instances of four contiguous amino acids in the sequence that are identical amino acid types or that the polypeptide has a subsequence score (defined infra) of 10 or less or that there isn't a pattern in the order, from N- to C-terminus, of the sequence motifs that constitute the polypeptide sequence. The term "repetitiveness" as used herein in the context of a polypeptide refers to the degree of internal homology in a peptide or polypeptide sequence. In contrast, a

"repetitive" sequence may contain multiple identical copies of short amino acid sequences. For instance, a polypeptide sequence of interest may be divided into n-mer sequences and the number of identical sequences can be counted. Highly repetitive sequences contain a large fraction of identical sequences while non-repetitive sequences contain few identical sequences. In the context of a polypeptide, a sequence can contain multiple copies of shorter sequences of defined or variable length, or motifs, in which the motifs themselves have non- repetitive sequences, rendering the full-length polypeptide substantially non-repetitive. The length of polypeptide within which the non-repetitiveness is measured can vary from 3 amino acids to about 200 amino acids, from about 6 to about 50 amino acids, or from about 9 to about 14 amino acids. "Repetitiveness" used in the context of polynucleotide sequences refers to the degree of internal homology in the sequence such as, for example, the frequency of identical nucleotide sequences of a given length. Repetitiveness can, for example, be measured by analyzing the frequency of identical sequences.

A "vector" is a nucleic acid molecule, preferably self-replicating in an appropriate host, which transfers an inserted nucleic acid molecule into and/or between host cells. The term includes vectors that function primarily for insertion of DNA or RNA into a cell, replication of vectors that function primarily for the replication of DNA or RNA, and expression vectors that function for transcription and/or translation of the DNA or RNA. Also included are vectors that provide more than one of the above functions. An "expression vector" is a polynucleotide which, when introduced into an appropriate host cell, can be transcribed and translated into a polypeptide(s). An "expression system" usually connotes a suitable host cell comprised of an expression vector that can function to yield a desired expression product.

"Serum degradation resistance," as applied to a polypeptide, refers to the ability of the polypeptides to withstand degradation in blood or components thereof, which typically involves proteases in the serum or plasma. The serum degradation resistance can be measured by combining the protein with human (or mouse, rat, monkey, as appropriate) serum or plasma, typically for a range of days (e.g. 0.25, 0.5, 1, 2, 4, 8, 16 days), typically at about 37°C. The samples for these time points can be run on a Western blot assay and the protein is detected with an antibody. The antibody can be to a tag in the protein. If the protein shows a single band on the western, where the protein's size is identical to that of the injected protein, then no degradation has occurred. In this exemplary method, the time point where 50% of the protein is degraded, as judged by Western blots or equivalent techniques, is the serum degradation half-life or "serum half-life" of the protein.

The term "tl/2 " as used herein means the terminal half-life calculated as ln(2)/K_ei . K_ei is the terminal elimination rate constant calculated by linear regression of the terminal linear portion of the log concentration vs. time curve. Half-life typically refers to the time required for half the quantity of an administered substance deposited in a living organism to be metabolized or eliminated by normal biological processes. The terms "tl/2 ", "terminal half-life", "elimination half-life" and "circulating half-life" are used interchangeably herein.

"Apparent Molecular Weight Factor" or "Apparent Molecular Weight" are related terms referring to a measure of the relative increase or decrease in apparent molecular weight exhibited by a particular amino acid sequence. The Apparent Molecular Weight is determined using size exclusion chromatography (SEC) and similar methods compared to globular protein standards and is measured in "apparent kD" units. The Apparent Molecular Weight Factor is the ratio between the Apparent Molecular Weight and the actual molecular weight; the latter predicted by adding, based on amino acid composition, the calculated molecular weight of each type of amino acid in the composition.

The "hydrodynamic radius" or "Stokes radius" is the effective radius (Rh in nm) of a molecule in a solution measured by assuming that it is a body moving through the solution and resisted by the solution's viscosity. In the embodiments of the disclosure, the

hydrodynamic radius measurements of the XTEN fusion proteins correlate with the

'Apparent Molecular Weight Factor', which is a more intuitive measure. The "hydrodynamic radius" of a protein affects its rate of diffusion in aqueous solution as well as its ability to migrate in gels of macromolecules. The hydrodynamic radius of a protein is determined by its molecular weight as well as by its structure, including shape and compactness. Methods for determining the hydrodynamic radius are well known in the art, such as by the use of size exclusion chromatography (SEC), as described in U.S. Patent Nos. 6,406,632 and 7,294,513. Most proteins have globular structure, which is the most compact three-dimensional structure a protein can have with the smallest hydrodynamic radius. Some proteins adopt a random and open, unstructured, or 'linear' conformation and as a result have a much larger hydrodynamic radius compared to typical globular proteins of similar molecular weight.

"Physiological conditions" refer to a set of conditions in a living host as well as in vitro conditions, including temperature, salt concentration, pH, that mimic those conditions of a living subject. A host of physiologically relevant conditions for use in in vitro assays have been established. Generally, a physiological buffer contains a physiological concentration of salt and is adjusted to a neutral pH ranging from about 6.5 to about 7.8, and preferably from about 7.0 to about 7.5. A variety of physiological buffers is listed in Sambrook et al. (1989). Physiologically relevant temperature ranges from about 25°C to about 38°C, and preferably from about 35°C to about 37°C.

A "reactive group" is a chemical structure that can be coupled to a second reactive group. Examples for reactive groups are amino groups, carboxyl groups, sulfhydryl groups, hydroxyl groups, aldehyde groups, azide groups. Some reactive groups can be activated to facilitate coupling with a second reactive group. Non-limiting examples for activation are the reaction of a carboxyl group with carbodiimide, the conversion of a carboxyl group into an activated ester, or the conversion of a carboxyl group into an azide function.

"Controlled release agent", "slow release agent", "depot formulation" or "sustained release agent" are used interchangeably to refer to an agent capable of extending the duration of release of a polypeptide of the disclosure relative to the duration of release when the polypeptide is administered in the absence of agent. Different embodiments of the present disclosure may have different release rates, resulting in different therapeutic amounts.

The terms "antigen", "target antigen" or "immunogen" are used interchangeably herein to refer to the structure or binding determinant that an antibody fragment or an antibody fragment-based therapeutic binds to or has specificity against. The term "payload" as used herein refers to a protein or peptide sequence that has biological or therapeutic activity; the counterpart to the pharmacophore of small molecules. Examples of payloads include, but are not limited to, cytokines, enzymes, hormones and blood and growth factors. Payloads can further comprise genetically fused or chemically conjugated moieties such as chemotherapeutic agents, antiviral compounds, toxins, or contrast agents. These conjugated moieties can be joined to the rest of the polypeptide via a linker that may be cleavable or non-cleavable.

The term "antagonist", as used herein, includes any molecule that partially or fully blocks, inhibits, or neutralizes a biological activity of a native polypeptide disclosed herein. Methods for identifying antagonists of a polypeptide may comprise contacting a native polypeptide with a candidate antagonist molecule and measuring a detectable change in one or more biological activities normally associated with the native polypeptide. In the context of the present disclosure, antagonists may include proteins, nucleic acids, carbohydrates, antibodies or any other molecules that decrease the effect of a biologically active protein.

The term "agonist" is used in the broadest sense and includes any molecule that mimics a biological activity of a native polypeptide disclosed herein. Suitable agonist molecules specifically include agonist antibodies or antibody fragments, fragments or amino acid sequence variants of native polypeptides, peptides, small organic molecules, etc.

Methods for identifying agonists of a native polypeptide may comprise contacting a native polypeptide with a candidate agonist molecule and measuring a detectable change in one or more biological activities normally associated with the native polypeptide.

"Activity" for the purposes herein refers to an action or effect of a component of a fusion protein consistent with that of the corresponding native biologically active protein, wherein "biological activity" refers to an in vitro or in vivo biological function or effect, including but not limited to receptor binding, antagonist activity, agonist activity, or a cellular or physiologic response.

As used herein, "treatment" or "treating," or "palliating" or "ameliorating" is used interchangeably herein. These terms refer to an approach for obtaining beneficial or desired results including but not limited to a therapeutic benefit and/or a prophylactic benefit. By therapeutic benefit is meant eradication or amelioration of the underlying disorder being treated. Also, a therapeutic benefit is achieved with the eradication or amelioration of one or more of the physiological symptoms associated with the underlying disorder such that an improvement is observed in the pediatric subject, notwithstanding that the subject may still be afflicted with the underlying disorder. For prophylactic benefit, the compositions may be administered to a pediatric subject at risk of developing a particular disease, or to a pediatric subject reporting one or more of the physiological symptoms of a disease, even though a diagnosis of this disease may not have been made.

A "therapeutic effect", as used herein, refers to a physiologic effect, including but not limited to the cure, mitigation, amelioration, or prevention of disease in humans or other animals, or to otherwise enhance physical or mental wellbeing of humans or animals, caused by a fusion polypeptide of the disclosure other than the ability to induce the production of an antibody against an antigenic epitope possessed by the biologically active protein.

Determination of a therapeutically effective amount is well within the capability of those skilled in the art, especially in light of the detailed disclosure provided herein.

The terms "therapeutically effective amount" and "therapeutically effective dose", as used herein, refers to an amount of a biologically active protein, either alone or as a part of a fusion protein composition, that is capable of having any detectable, beneficial effect on any symptom, aspect, measured parameter or characteristics of a disease state or condition when administered in one or repeated doses to a pediatric subject. Such effect need not be absolute to be beneficial. For example, such effect may entail increasing the height of said pediatric patient.

A "pharmaceutically acceptable carrier" refers to an ingredient in a pharmaceutical composition, other than an active ingredient, which is nontoxic to a pediatric subject. A pharmaceutically acceptable carrier includes, but is not limited to, a buffer, an excipient, a stabilizer, or preservative.

The term "therapeutically effective dose regimen", as used herein, refers to a schedule for consecutively administered doses of a biologically active protein, either alone or as a part of a fusion protein composition, wherein the doses are given in therapeutically effective amounts to result in sustained beneficial effect on any symptom, aspect, measured parameter or characteristics of a disease state or condition.

The term "pediatric patient", "pediatric subject", as used herein, refers to an individual who is not an adult. Pediatric patients include infants, children, and adolescents. In one embodiment, the children are pre-adolescent or pre-pubertal individuals. In another embodiment, the pediatric patient is a human patient.

The term "height velocity", as used herein, refers to the rate of increase of the pediatric patient's height over a period of time. I). GENERAL TECHNIQUES

The practice of various embodiments of the present disclosure employs, unless otherwise indicated, conventional techniques of immunology, biochemistry, chemistry, molecular biology, microbiology, cell biology, genomics and recombinant DNA, which are within the skill of the art. See Sambrook, J. et al., "Molecular Cloning: A Laboratory Manual," 3rd edition, Cold Spring Harbor Laboratory Press, 2001; "Current protocols in molecular biology", F. M. Ausubel, et al. eds., 1987; the series "Methods in Enzymology," Academic Press, San Diego, CA.; "PCR 2: a practical approach", M.J. MacPherson, B.D. Hames and G.R. Taylor eds., Oxford University Press, 1995; "Antibodies, a laboratory manual" Harlow, E. and Lane, D. eds., Cold Spring Harbor Laboratory, 1988; "Goodman & Gilman's The Pharmacological Basis of Therapeutics," 11th Edition, McGraw-Hill, 2005; and Freshney, R.I., "Culture of Animal Cells: A Manual of Basic Technique," 4th edition, John Wiley & Sons, Somerset, NJ, 2000, the contents of which are incorporated in their entirety herein by reference.

II). GROWTH HORMONE

The present disclosure provides, in some embodiments, an improved therapeutic regimen for treating pediatric growth hormone deficiency (PGHD) patients. In some embodiments, the disclosure provides methods for bolus dose administration of a hGH- XTEN fusion protein to a pediatric patient with PGHD. In one aspect, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in pediatric patients with a hGH-XTEN fusion protein,

(a) Growth hormone proteins

"Growth Hormone" or "GH" means a growth hormone protein and species and sequence variants thereof, and includes, but is not limited to, the 191 single-chain amino acid sequence of human GH. The GH can be the native, full-length protein or can be a truncated fragment or a sequence variant that retains at least a portion of the biological activity of the native protein. There are two known types of human GH (hereinafter "hGH") derived from the pituitary gland: one having a molecular weight of about 22, 129 daltons (22kD hGH) and the other having a molecular weight of about 20,000 daltons (20kD hGH). The 20kD HGH has an amino acid sequence that corresponds to that of 22kD hGH consisting of 191 amino acids except that 15 amino acid residues from the 32nd to the 46th of 22kD hGH are missing. Some reports have shown that the 20kD hGH has been found to exhibit lower risks and higher activity than 22kD hGH. In some embodiments, the method described herein contemplates use of the 22 kD, the 20kD hGH, as well as species and sequence variants and truncated fragments thereof as being appropriate for use as a fusion partner with XTEN disclosed herein for hGH-XTEN compositions. The cloned gene for hGH has been expressed in a secreted form in Eschericha coli (United States Patent No. 4,898,830; Chang, C. N., et al., Gene 55: 189 [1987]) and its DNA and amino acid sequence has been reported (Goeddel, et al. Nature ,281 :544 [1979]); Gray, et al., Gene 39: 247[1985]).

In some embodiments, the method described herein contemplates inclusion in the hGH-XTEN compositions sequences with homology to GH sequences, sequence fragments that are natural, such as from humans and non-natural sequence variants which retain at least a portion of the biologic activity or biological function of GH and/or that are useful for preventing, treating, mediating, or ameliorating a GH-related disease, deficiency, disorder or condition in pediatric patients. In addition, native sequences homologous to human GH may be found by standard homology searching techniques, such as NCBI BLAST.

Effects of GH on the tissues of the body can generally be described as anabolic. Like most other protein hormones, native GH acts by interacting with a specific plasma membrane receptor, referred to as growth hormone receptor. GH acts on the liver and other tissues to stimulate production of IGF-I, which is responsible for the growth promoting effects of GH and also reflects the amount produced. IGF-I, in turn, has stimulatory effects on osteoblast and chondrocyte activity to promote bone growth. In one embodiment, the disclosure provides a hGH-XTEN that exhibits at least one of the properties of native GH hereinabove described herein.

In one embodiment, the GH incorporated into the subject compositions is a recombinant polypeptide with a sequence corresponding to a protein found in nature. In another embodiment, the GH is a sequence variant, fragment, homolog, or a mimetics of a natural sequence that retains at least a portion of the biological activity of the corresponding native GH. In one other embodiment, the GH is human GH comprising the following amino acid sequence:

FPTIPLSRLFDNAMLRAHRLHQLAFDTYQEFEEAYIPKEQKYSFLQNPQTSLCFSESIP TPSNREETQQKSNLELLRISLLLIQSWLEPVQFLRSVFANSLVYGASDSNVYDLLKDL EEGIQTLMGRLEDGSPRTGQIFKQTYSKFDTNSHNDDALLKNYGLLYCFRKDMDKV ETFLRIVQCRSVEGSCGF (SEQ ID NO:41). Any human GH sequences or homologous derivatives constructed by shuffling individual mutations between families that retain at least a portion of the biological activity of the native GH may be useful for the fusion proteins of the present disclosure. GH that can be incorporated into a hGH-XTEN fusion protein can include a protein that exhibits at least about 80% sequence identity, or alternatively 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% sequence identity to SEQ ID NO:41.

III). HUMAN GROWTH HORMONE-XTEN FUSION PROTEIN COMPOSITIONS FOR TREATING PGHD

In some embodiments, the present disclosure provides an improved therapeutic regimen for pediatric growth hormone deficiency (PGHD) therapy for pediatric patients. In some embodiments, the disclosure provides methods for bolus dose administration of hGH- XTEN fusion proteins to a pediatric patient with PGHD. In one aspect, the hGH fusion proteins suitable for uses described herein comprise a human growth hormone polypeptide and one or more XTEN sequences as described herein, and as disclosed in Schellenberger et al. WO10/144502A2 and WO10/091122, which are incorporated herein by reference in their entirety.

In one other aspect, the hGH-XTEN fusion proteins are isolated monomeric fusion proteins of GH comprising the full-length sequence or sequence variants of GH covalently linked to one or more extended recombinant polypeptides ("XTEN" or "XTENs"). In one embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence shown in FIG. 1 (SEQ ID NO: 1), or pharmacologically active variants thereof. In another

embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence selected from Table 1.

For example, the hGH-XTEN fusion protein VRS-317, is composed of recombinant human growth hormone (rhGH) and two recombinant polypeptides, referred to as XTEN as described in Schellenberger et al. (2009). Nat Biotechnol 27, 1186-90, Schellenberger et al. WO10/144502A2, and WO10/091122, each of which are incorporated herein by reference in their entirety. The XTEN domain, two unstructured hydrophilic chains of amino acids, provides half-life extension for rhGH. The molecular weight of VRS-317 is 118.9 kDa, with rhGH contributing 22.1 kDa and the remaining mass contributed by the XTEN construct. The mass ratio of rhGH to VRS-317 is therefore 1 :5.37.

Table 1 - Exemplary hGH-XTEN fusion proteins

liGH 1I<3 MM.

ΧΊ^'Γ.Ν Amino Sl'(|I 'IKT ID Nuck-olirii- SI-(|I -IKT II)

Nii iiK'" ii NO

EGSAPGTSTEPSEGSAP CTACTCCTGAGTCTGGTCCAGGTACCTCTACTG

GTSESATPESGPGSEPA AACCGTCCGAAGGTAGCGCTCCAGGTAGCCCA

TSGSETPGSEPATSGSET GCAGGCTCTCCGACTTCCACTGAGGAAGGTACT

PGSPAGSPTSTEEGTSES TCTACTGAACCTTCCGAAGGCAGCGCACCAGGT

ATPESGPGTSTEPSEGS ACCTCTACTGAACCTTCTGAGGGCAGCGCTCCA

APGTSTEPSEGSAPGSP GGTACTTCTGAAAGCGCTACCCCGGAATCTGGC

AGSPTSTEEGTSTEPSE CCAGGTAGCGAACCGGCTACTTCTGGTTCTGAA

GSAPGTSTEPSEGSAPG ACCCCAGGTAGCGAACCGGCTACCTCCGGTTCT

TSESATPESGPGTSTEPS GAAACTCCAGGTAGCCCGGCAGGCTCTCCGACC

EGSAPGTSESATPESGP TCTACTGAGGAAGGTACTTCTGAAAGCGCAACC

GSEPATSGSETPGTSTEP CCGGAGTCCGGCCCAGGTACCTCTACCGAACCG

SEGSAPGTSTEPSEGSA TCTGAGGGCAGCGCACCAGGTACTTCTACCGAA

PGTSESATPESGPGTSES CCGTCCGAGGGTAGCGCACCAGGTAGCCCAGC

ATPESGPGSPAGSPTST AGGTTCTCCTACCTCCACCGAGGAAGGTACTTC

EEGTSESATPESGPGSEP TACCGAACCGTCCGAGGGTAGCGCACCAGGTA

ATSGSETPGTSESATPES CCTCTACTGAACCTTCTGAGGGCAGCGCTCCAG

GPGTSTEPSEGSAPGTS GTACTTCTGAAAGCGCTACCCCGGAGTCCGGTC

TEPSEGSAPGTSTEPSEG CAGGTACTTCTACTGAACCGTCCGAAGGTAGCG

SAPGTSTEPSEGSAPGT CACCAGGTACTTCTGAAAGCGCAACCCCTGAAT

STEPSEGSAPGTSTEPSE CCGGTCCAGGTAGCGAACCGGCTACTTCTGGCT

GSAPGSPAGSPTSTEEG CTGAGACTCCAGGTACTTCTACCGAACCGTCCG

TSTEPSEGSAPGTSESAT AAGGTAGCGCACCAGGTACTTCTACTGAACCGT

PESGPGSEPATSGSETP CTGAAGGTAGCGCACCAGGTACTTCTGAAAGCG

GTSESATPESGPGSEPA CAACCCCGGAATCCGGCCCAGGTACCTCTGAAA

TSGSETPGTSESATPESG GCGCAACCCCGGAGTCCGGCCCAGGTAGCCCTG

PGTSTEPSEGSAPGTSES CTGGCTCTCCAACCTCCACCGAAGAAGGTACCT

ATPESGPGSPAGSPTST CTGAAAGCGCAACCCCTGAATCCGGCCCAGGTA

EEGSPAGSPTSTEEGSP GCGAACCGGCAACCTCCGGTTCTGAAACCCCAG

AGSPTSTEEGTSESATP GTACCTCTGAAAGCGCTACTCCGGAGTCTGGCC

ESGPGTSTEPSEGSAPG CAGGTACCTCTACTGAACCGTCTGAGGGTAGCG

TSESATPESGPGSEPATS CTCCAGGTACTTCTACTGAACCGTCCGAAGGTA

GSETPGTSESATPESGP GCGCACCAGGTACTTCTACCGAACCGTCCGAAG

GSEPATSGSETPGTSES GCAGCGCTCCAGGTACCTCTACTGAACCTTCCG

ATPESGPGTSTEPSEGS AGGGCAGCGCTCCAGGTACCTCTACCGAACCTT

APGSPAGSPTSTEEGTS CTGAAGGTAGCGCACCAGGTACTTCTACCGAAC

ESATPESGPGSEPATSG CGTCCGAGGGTAGCGCACCAGGTAGCCCAGCA

SETPGTSESATPESGPGS GGTTCTCCTACCTCCACCGAGGAAGGTACTTCT

PAGSPTSTEEGSPAGSP ACCGAACCGTCCGAGGGTAGCGCACCAGGTAC

TSTEEGTSTEPSEGSAP CTCTGAAAGCGCAACTCCTGAGTCTGGCCCAGG

GTSESATPESGPGTSES TAGCGAACCTGCTACCTCCGGCTCTGAGACTCC

ATPESGPGTSESATPES AGGTACCTCTGAAAGCGCAACCCCGGAATCTGG

GPGSEPATSGSETPGSE TCCAGGTAGCGAACCTGCAACCTCTGGCTCTGA

PATSGSETPGSPAGSPTS AACCCCAGGTACCTCTGAAAGCGCTACTCCTGA

TEEGTSTEPSEGSAPGT ATCTGGCCCAGGTACTTCTACTGAACCGTCCGA

STEPSEGSAPGSEPATS GGGCAGCGCACCAGGTACTTCTGAAAGCGCTAC

GSETPGTSESATPESGP TCCTGAGTCCGGCCCAGGTAGCCCGGCTGGCTC

GTSTEPSEGSAPGFPTIP TCCGACTTCCACCGAGGAAGGTAGCCCGGCTGG

LSRLFDNAMLRAHRLH CTCTCCAACTTCTACTGAAGAAGGTAGCCCGGC

QLAFDTYQEFEEAYIPK AGGCTCTCCGACCTCTACTGAGGAAGGTACTTC

EQKYSFLQNPQTSLCFS TGAAAGCGCAACCCCGGAGTCCGGCCCAGGTA

ESIPTP SNREETQQKSNL CCTCTACCGAACCGTCTGAGGGCAGCGCACCAG

ELLPJSLLLIQSWLEPVQ GTACCTCTGAAAGCGCAACTCCTGAGTCTGGCC

FLRS VF ANSL VYG ASD S CAGGTAGCGAACCTGCTACCTCCGGCTCTGAGA

NVYDLLKDLEEGIQTL CTCCAGGTACCTCTGAAAGCGCAACCCCGGAAT

MGRLEDGSPRTGQIFK CTGGTCCAGGTAGCGAACCTGCAACCTCTGGCT

QTYSKFDTNSHNDDAL CTGAAACCCCAGGTACCTCTGAAAGCGCTACTC

LKNYGLLYCFRKDMD CTGAATCTGGCCCAGGTACTTCTACTGAACCGT

liGH 1I<3 MM.

ΧΊ^'Γ.Ν Amino Sl'(|I 'IKT ID Nuck-olirii- SI-(|I -IKT II)

Nii iiK'" ii NO

GTSTPESGSASPGTSTPE ACTCCGGAAAGCGGCTCTGCATCTCCAGGTTCT

SGSASPGSEPATSGSETP ACTAGCGAATCTCCTTCTGGCACTGCACCAGGT

GTSESATPESGPGSPAG TCTACTAGCGAATCCCCGTCTGGTACTGCTCCA

SPTSTEEGTSTEPSEGSA GGTACTTCTACTCCTGAAAGCGGTTCCGCTTCTC

PGTSESATPESGPGTSTE CAGGTACCTCTACTCCGGAAAGCGGTTCTGCAT

PSEGSAPGTSTEPSEGS CTCCAGGTAGCGAACCGGCAACCTCCGGCTCTG

APGSPAGSPTSTEEGTS AAACCCCAGGTACCTCTGAAAGCGCTACTCCTG

TEPSEGSAPGTSTEPSEG AATCCGGCCCAGGTAGCCCGGCAGGTTCTCCGA

SAPGTSESATPESGPGT CTTCCACTGAGGAAGGTACCTCTACTGAACCTT

SESATPESGPGTSTEPSE CTGAGGGCAGCGCTCCAGGTACTTCTGAAAGCG

GSAPGTSTEPSEGSAPG CTACCCCGGAGTCCGGTCCAGGTACTTCTACTG

TSESATPESGPGTSTEPS AACCGTCCGAAGGTAGCGCACCAGGTACTTCTA

EGSAPGSEPATSGSETP CCGAACCGTCCGAGGGTAGCGCACCAGGTAGC

GSPAGSPTSTEEGS STPS CCAGCAGGTTCTCCTACCTCCACCGAGGAAGGT

GATGSPGTPGS GT AS S S ACTTCTACCGAACCGTCCGAGGGTAGCGCACCA

PGSSTPSGATGSPGTST GGTACTTCTACCGAACCTTCCGAGGGCAGCGCA

EPSEGSAPGTSTEPSEGS CCAGGTACTTCTGAAAGCGCTACCCCTGAGTCC

APGSEPATSGSETPGSP GGCCCAGGTACTTCTGAAAGCGCTACTCCTGAA

AGSPTSTEEGSPAGSPT TCCGGTCCAGGTACCTCTACTGAACCTTCCGAA

STEEGTSTEPSEGSAPG GGCAGCGCTCCAGGTACCTCTACCGAACCGTCC

ASASGAPSTGGTSESAT GAGGGCAGCGCACCAGGTACTTCTGAAAGCGC

PESGPGSPAGSPTSTEE AACCCCTGAATCCGGTCCAGGTACTTCTACTGA

GSPAGSPTSTEEGSTSST ACCTTCCGAAGGTAGCGCTCCAGGTAGCGAACC

AESPGPGSTSESPSGTAP TGCTACTTCTGGTTCTGAAACCCCAGGTAGCCC

GTSPSGESSTAPGTPGS GGCTGGCTCTCCGACCTCCACCGAGGAAGGTAG

GTASSSPGSSTPSGATG CTCTACCCCGTCTGGTGCTACTGGTTCTCCAGGT

SPGSSPSASTGTGPGSEP ACTCCGGGCAGCGGTACTGCTTCTTCCTCTCCA

ATSGSETPGTSESATPES GGTAGCTCTACCCCTTCTGGTGCTACTGGCTCTC

GPGSEPATSGSETPGST CAGGTACCTCTACCGAACCGTCCGAGGGTAGCG

SSTAESPGPGSTSSTAES CACCAGGTACCTCTACTGAACCGTCTGAGGGTA

PGPGTSPSGESSTAPGSE GCGCTCCAGGTAGCGAACCGGCAACCTCCGGTT

PATSGSETPGSEPATSG CTGAAACTCCAGGTAGCCCTGCTGGCTCTCCGA

SETPGTSTEPSEGSAPGS CTTCTACTGAGGAAGGTAGCCCGGCTGGTTCTC

TSSTAESPGPGTSTPESG CGACTTCTACTGAGGAAGGTACTTCTACCGAAC

SASPGSTSESPSGTAPGT CTTCCGAAGGTAGCGCTCCAGGTGCAAGCGCAA

STEPSEGSAPGTSTEPSE GCGGCGCGCCAAGCACGGGAGGTACTTCTGAA

GSAPGTSTEPSEGSAPG AGCGCTACTCCTGAGTCCGGCCCAGGTAGCCCG

SSTPSGATGSPGSSPSAS GCTGGCTCTCCGACTTCCACCGAGGAAGGTAGC

TGTGPGASPGTSSTGSP CCGGCTGGCTCTCCAACTTCTACTGAAGAAGGT

GSEPATSGSETPGTSES TCTACCAGCTCTACCGCTGAATCTCCTGGCCCA

ATPESGPGSPAGSPTST GGTTCTACTAGCGAATCTCCGTCTGGCACCGCA

EEGSSTPSGATGSPGSSP CCAGGTACTTCCCCTAGCGGTGAATCTTCTACT

SASTGTGPGASPGTSST GCACCAGGTACCCCTGGCAGCGGTACCGCTTCT

GSPGTSESATPESGPGT TCCTCTCCAGGTAGCTCTACCCCGTCTGGTGCTA

STEPSEGSAPGTSTEPSE CTGGCTCTCCAGGTTCTAGCCCGTCTGCATCTAC

GSAPGFPTIPLSRLFDNA CGGTACCGGCCCAGGTAGCGAACCGGCAACCT

MLRAHRLHQLAFDTYQ CCGGCTCTGAAACTCCAGGTACTTCTGAAAGCG

EFEEAYIPKEQKYSFLQ CTACTCCGGAATCCGGCCCAGGTAGCGAACCGG

NPQTSLCFSESIPTPSNR CTACTTCCGGCTCTGAAACCCCAGGTTCCACCA

EETQQKSNLELLPJSLL GCTCTACTGCAGAATCTCCGGGCCCAGGTTCTA

LIQSWLEPVQFLRSVFA CTAGCTCTACTGCAGAATCTCCGGGTCCAGGTA

NSL VYG ASD SNVYDLL CTTCTCCTAGCGGCGAATCTTCTACCGCTCCAG

KDLEEGIQTLMGRLED GTAGCGAACCGGCAACCTCTGGCTCTGAAACTC

GSPRTGQIFKQTYSKFD CAGGTAGCGAACCTGCAACCTCCGGCTCTGAAA

TNSHNDDALLKNYGLL CCCCAGGTACTTCTACTGAACCTTCTGAGGGCA

YCFRKDMDKVETFLRI GCGCACCAGGTTCTACCAGCTCTACCGCAGAAT

VQCRSVEGSCGF CTCCTGGTCCAGGTACCTCTACTCCGGAAAGCG h(; i i- SEQ SEQ

XTEN VmiiiD \cid SI'<|I 'IKT ID DN \ Niickolidc S(.'(|i 'iK ' ID NiliiK'" NO: NO:

GCTCT GCATCTCCAGGTTCTACTAGCGAA^r rCTC

CTTCT GGCACTGCACCAGGTACTTCTACC( JAAC CGTCC GAAGGCAGCGCTCCAGGTACCTCT ACTG AACCl CCGAGGGCAGCGCTCCAGGTACC TCTA CCGA^ ^CCTTCTGAAGGTAGCGCACCAGGl AGCT CTACT CCGTCTGGTGCAACCGGCTCCCCA( 3GTT

CTAGC :CCGTCTGCTTCCACTGGTACTGGC( XAG

GTGCl TCCCCGGGCACCAGCTCTACTGGT^r rCTC

CAGG1 "AGCGAACCTGCTACCTCCGGTTCT GAAA CCCC^ LGGTACCTCTGAAAGCGCAACTCCG GAGT CTGGl CCAGGTAGCCCTGCAGGTTCTCCT, \CCT

CCACl GAGGAAGGTAGCTCTACTCCGTCT GGTG CAACC GGCTCCCCAGGTTCTAGCCCGTCT 3CTT

CCACl GGTACTGGCCCAGGTGCTTCCCCG GGCA CCAGC TCTACTGGTTCTCCAGGTACCTCTC iAAA

GCGCl "ACTCCGGAGTCTGGCCCAGGTACC TCTA CTGAA LCCGTCTGAGGGTAGCGCTCCAGGT ACTT CTACT GAACCGTCCGAAGGTAGCGCACC^ LGGTT TTCCG ACTATTCCGCTGTCTCGTCTGTTTG ATAA TGCTA .TGCTGCGTGCGCACCGTCTGCACC \GCT GGCCl TGATACTTACCAGGAATTTGAAG AAGC cTACA TTCCTAAAGAGCAGAAGTACTCTT1 rCCTG

CAAA ^CCCACAGACTTCTCTCTGCTTCAG⁽ ZGAA

TCTAT TCCGACGCCTTCCAATCGCGAGGA AACT

TCTCT GCTTCTGATTCAGAGCTGGCTAGA CCA GTGC^ LATTTCTGCGTTCCGTCTTCGCCAAI MGCC TAGTT TATGGCGCATCCGACAGCAACGTA TACG ATCTC CTGAAAGATCTCGAGGAAGGCATT CAGA CCCTG rATGGGTCGTCTCGAGGATGGCTCT CCGC GTACl GGTCAGATCTTCAAGCAGACTTAC TCTA

AATTT GATACTAACAGCCACAATGACGAT GCGC TTCTA AAAAACTATGGTCTGCTGTATTGTl rTTCG TAAAC iATATGGACAAAGTTGAAACCTTCC TGCG TATTG TTCAGTGTCGTTCCGTTGAGGGCA( JCTG

TGGTT TC

Y576- GI iGSGEGSEGEGSEGSG 3 GGTG^ ^GGGTTCTGGCGAAGGTTCCGAAGC iTGA 9 hGH EC iEGSEGSGEGEGGSE GGGCl TCGAAGGATCTGGCGAAGGTGAGI JGTT

Gi JEGEGSEGSGEGEGG CCGA^ ^GGTTCTGGCGAAGGTGAAGGCGG^R rTCTG EC iSGEGEGSGEGSEGE AGGG^ VTCCGAAGGTGAAGGCTCCGAAGG ATCT G( JGEGSEGEGSGEGGE GGCG^ ^AGGTGAAGGTGGTGAAGGTTCTG( JCGA GI iGSEGGSEGEGGSEG AGGTC IAGGGATCTGGCGAAGGCTCTGAA( JGTG GI iGEGSEGSGEGEGSE AAGGl RGGTGGTGAAGGCTCTGAAGGTGA^ GGA G( JSEGEGSEGGSEGEGS TCTGG RTGAAGGTGGCGAAGGTGAGGGAT( :TGA EC iSGEGEGSEGSGEGE AGGCC IGCTCCGAAGGTGAAGGCGGATCT( JAAG Gi LEGSGEGEGSEGSGEG GCGGC GAAGGTGAAGGTTCCGAAGGTTCI "GGT EC iSEGGSEGEGGSEGSE

GI iGSGEGSEGEGGSEGS TGAAC IGATCTGAAGGCGGTTCCGAAGGTC iAGG EC iEGGGEGSEGEGSGE GCTCT GAAGGTTCTGGCGAAGGTGAAGGC TCTG Gi JEGEGGSEGSEGEGGS

EC iSEGEGGEGSGEGEG TCTGG RTGAAGGTGAAGGTTCCGAAGGTTC TGGC SE GSGEGEGSGEGSEGE

Gi LEGSGEGEGSEGSGEG TGAAC iGCGGCTCTGAAGGATCCGAAGGTC JAAG EC iGSEGSEGEGSGEGSE GTTCT GGTGAAGGCTCTGAAGGTGAAGGC :GGCT GI iGSEGSGEGEGSEGSG CTGAC iGGTTCCGAAGGTGAAGGCGGAGGf ZGAA EC iEGGSEGSEGEGGSE GGTTC TGAAGGTGAGGGATCTGGTGAAGC iTTCT h(; i i- SEQ SEQ

XTEN \in iii \cid SI'<|I 'IKT ID DN \ Niickolidc S(.'(|i 'iK ' ID NiliiK'" NO: NO:

Gi JEGEGGSEGSEGEGG

EC iSGEGEGSEGSGEGE TGAAC iGTGGCTCTGAGGGATCCGAAGGTC iAAG Gi JGEGSEGEGSEGSGEG GTGGC GAAGGATCTGGTGAAGGTGAAGG^r rTCT EC iSEGSGEGEGGSEGSE GAAG( JTTCTGGCGAAGGTGAGGGTTCTGC iCGA GI iGSEGSGEGEGGEGS AGGTl ^,CCGAAGGTGAGGGCTCCGAAGGA^r rCTG GI iGEGSGEGSEGEGGG

EC iSEGEGSEGSGEGEGS GGTG^ ^AGGCGGTTCTGAGGGATCCGAAGC JTGA EC iSGEGEGSEGGSEGE GGGTl "CTGGCGAAGGTTCCGAAGGTGAGC iGCTC G( JSEGSEGEGSEGGSEG CGAAC iGATCTGGCGAAGGTGAGGGTTCCC iAAG EC iSEGGSEGEGSEGSGE GTTCT GGCGAAGGTGAAGGCGGTTCTGAC iGGAT GI iGSEGSGEGEGSGEGS CCGA^ 'LGGTGAAGGCGGTTCTGAAGGTTCC :GAA EC iEGGSEGGEGEGSEG GGTG^ ^AGGTGGCTCTGAGGGATCCGAAGC JTGA Gi JEGEGSEGGSEGEGG AGGTC iGCGAAGGATCTGGTGAAGGTGAA( 3GTT EC iSGEGEGGGEGSEGE CTGAA LGGTTCTGGCGAAGGTGAGGGTTCT GGCG Gi JEGSGEGEGSGEGSEG AAGGl [TCCGAAGGTGAGGGCTCCGAAGG; VTCT FP TIPLSRLFDNAMLRA

HI LHQLAFDTYQEFEE AGGTC iAAGGCGGTTCTGAGGGATCCGAAC JGTG flPKEQKYSFLQNPQT

SL CFSESIPTPSNREETQ GGTG^ ^AGGTTCTGGCGAAGGTGAGGGATC :TGG QI CSNLELLRISLLLIQS CGAAC JGCTCTGAAGGTGAAGGTGGTGGTC iAAG W LEPVQFLRSVFANSL GCTCT GAAGGTGAAGGTTCCGAAGGTTCT GGTG

ί GASDSNVYDLLKDL

EE .GIQTLMGRLEDGSPR

TC iQIFKQTYSKFDTNSH CGGCl ^,CTGAAGGATCCGAAGGTGAAGGA^r rCTG NI )DALLKNYGLLYCFR AAGGl rGGCTCCGAAGGTGAAGGATCTGA^ GGC KI )MDKVETFLRIVQCR GGTTC CGAAGGTGAGGGCTCTGAAGGTTC TGGC s\ TiGSCGF

TGAAC iGATCTGGCGAAGGCTCCGAAGGTC iAAG

VTCT

TGGCl CTGAAGGTGAAGGTGGCGAAGGTL CTGG CGAAC IGTGAAGGTGGAGGCGAAGGTTCT( 3AAG GTGA^ ^GGTTCCGAAGGTTCTGGTGAAGGL AG

GGATC TGGCGAAGGTTCTGAAGGTTTTCC GACT ATTCC GCTGTCTCGTCTGTTTGATAACGCL "ATGC TGCGl GCGCACCGTCTGCACCAGCTGGCG TTCG ACACl TACCAGGAATTTGAAGAAGCGTAC :ATTC CGAAC IGAACAGAAGTACTCTTTCCTGCAA AACC CGCAC IACCTCCCTGTGCTTCAGCGAATCT, ATTC

CGACl "CCGTCCAATCGTGAAGAAACTCAG rCAAA AGTCC :AATCTGGAGCTGCTGCGCATCTCT DTGC

TGCTG RATTCAGAGCTGGCTGGAGCCTGTT CAGT TTCTG CGTTCCGTCTTCGCCAACAGCCTGC JTTTA TGGTC RCTTCCGACAGCAACGTATACGATC TGCT GAAA( JATCTGGAAGAAGGCATTCAGACCC TGA

TGGGl "CGTCTGGAAGATGGTTCTCCGCGT ACTG GTCAC JATCTTCAAACAAACTTACTCCAAA TTTG ATACl AACAGCCATAACGACGATGCTCTG CTGA AAAAC ITATGGTCTGCTGTATTGCTTCCGQ AGG ATATC RGACAAAGTTGAAACCTTCCTGCGT ATTG TGCAC JTGTCGTTCCGTTGAGGGCAGCTGT GGTT TC

AE912- AI iPAGSPTSTEEGTPGS 4 ATGGC TGAACCTGCTGGCTCTCCAACCTC⁽ 2ACT 10 hGH GI rASSSPGSSTPSGATG GAGG^ AGGTACCCCGGGTAGCGGTACTGC :TTCT

SP GASPGTSSTGSPGSP TCCTC TCCAGGTAGCTCTACCCCTTCTGG1 OCAA A( JSPTSTEEGTSESATP CCGGC TCTCCAGGTGCTTCTCCGGGCACC \GCT liGH 1I<3 MM.

ΧΊ^'Γ.Ν Amino Sl'(|I 'IKT ID Nuck-olirii- SI-(|I -IKT II)

Nii iiK'" ii NO

ESGPGTSTEPSEGSAPG CTACCGGTTCTCCAGGTAGCCCGGCTGGCTCTC

SPAGSPTSTEEGTSTEPS CTACCTCTACTGAGGAAGGTACTTCTGAAAGCG

EGSAPGTSTEPSEGSAP CTACTCCTGAGTCTGGTCCAGGTACCTCTACTG

GTSESATPESGPGSEPA AACCGTCCGAAGGTAGCGCTCCAGGTAGCCCA

TSGSETPGSEPATSGSET GCAGGCTCTCCGACTTCCACTGAGGAAGGTACT

PGSPAGSPTSTEEGTSES TCTACTGAACCTTCCGAAGGCAGCGCACCAGGT

ATPESGPGTSTEPSEGS ACCTCTACTGAACCTTCTGAGGGCAGCGCTCCA

APGTSTEPSEGSAPGSP GGTACTTCTGAAAGCGCTACCCCGGAATCTGGC

AGSPTSTEEGTSTEPSE CCAGGTAGCGAACCGGCTACTTCTGGTTCTGAA

GSAPGTSTEPSEGSAPG ACCCCAGGTAGCGAACCGGCTACCTCCGGTTCT

TSESATPESGPGTSTEPS GAAACTCCAGGTAGCCCGGCAGGCTCTCCGACC

EGSAPGTSESATPESGP TCTACTGAGGAAGGTACTTCTGAAAGCGCAACC

GSEPATSGSETPGTSTEP CCGGAGTCCGGCCCAGGTACCTCTACCGAACCG

SEGSAPGTSTEPSEGSA TCTGAGGGCAGCGCACCAGGTACTTCTACCGAA

PGTSESATPESGPGTSES CCGTCCGAGGGTAGCGCACCAGGTAGCCCAGC

ATPESGPGSPAGSPTST AGGTTCTCCTACCTCCACCGAGGAAGGTACTTC

EEGTSESATPESGPGSEP TACCGAACCGTCCGAGGGTAGCGCACCAGGTA

ATSGSETPGTSESATPES CCTCTACTGAACCTTCTGAGGGCAGCGCTCCAG

GPGTSTEPSEGSAPGTS GTACTTCTGAAAGCGCTACCCCGGAGTCCGGTC

TEPSEGSAPGTSTEPSEG CAGGTACTTCTACTGAACCGTCCGAAGGTAGCG

SAPGTSTEPSEGSAPGT CACCAGGTACTTCTGAAAGCGCAACCCCTGAAT

STEPSEGSAPGTSTEPSE CCGGTCCAGGTAGCGAACCGGCTACTTCTGGCT

GSAPGSPAGSPTSTEEG CTGAGACTCCAGGTACTTCTACCGAACCGTCCG

TSTEPSEGSAPGTSESAT AAGGTAGCGCACCAGGTACTTCTACTGAACCGT

PESGPGSEPATSGSETP CTGAAGGTAGCGCACCAGGTACTTCTGAAAGCG

GTSESATPESGPGSEPA CAACCCCGGAATCCGGCCCAGGTACCTCTGAAA

TSGSETPGTSESATPESG GCGCAACCCCGGAGTCCGGCCCAGGTAGCCCTG

PGTSTEPSEGSAPGTSES CTGGCTCTCCAACCTCCACCGAAGAAGGTACCT

ATPESGPGSPAGSPTST CTGAAAGCGCAACCCCTGAATCCGGCCCAGGTA

EEGSPAGSPTSTEEGSP GCGAACCGGCAACCTCCGGTTCTGAAACCCCAG

AGSPTSTEEGTSESATP GTACCTCTGAAAGCGCTACTCCGGAGTCTGGCC

ESGPGTSTEPSEGSAPG CAGGTACCTCTACTGAACCGTCTGAGGGTAGCG

TSESATPESGPGSEPATS CTCCAGGTACTTCTACTGAACCGTCCGAAGGTA

GSETPGTSESATPESGP GCGCACCAGGTACTTCTACCGAACCGTCCGAAG

GSEPATSGSETPGTSES GCAGCGCTCCAGGTACCTCTACTGAACCTTCCG

ATPESGPGTSTEPSEGS AGGGCAGCGCTCCAGGTACCTCTACCGAACCTT

APGSPAGSPTSTEEGTS CTGAAGGTAGCGCACCAGGTACTTCTACCGAAC

ESATPESGPGSEPATSG CGTCCGAGGGTAGCGCACCAGGTAGCCCAGCA

SETPGTSESATPESGPGS GGTTCTCCTACCTCCACCGAGGAAGGTACTTCT

PAGSPTSTEEGSPAGSP ACCGAACCGTCCGAGGGTAGCGCACCAGGTAC

TSTEEGTSTEPSEGSAP CTCTGAAAGCGCAACTCCTGAGTCTGGCCCAGG

GTSESATPESGPGTSES TAGCGAACCTGCTACCTCCGGCTCTGAGACTCC

ATPESGPGTSESATPES AGGTACCTCTGAAAGCGCAACCCCGGAATCTGG

GPGSEPATSGSETPGSE TCCAGGTAGCGAACCTGCAACCTCTGGCTCTGA

PATSGSETPGSPAGSPTS AACCCCAGGTACCTCTGAAAGCGCTACTCCTGA

TEEGTSTEPSEGSAPGT ATCTGGCCCAGGTACTTCTACTGAACCGTCCGA

STEPSEGSAPGSEPATS GGGCAGCGCACCAGGTACTTCTGAAAGCGCTAC

GSETPGTSESATPESGP TCCTGAGTCCGGCCCAGGTAGCCCGGCTGGCTC

GTSTEPSEGSAPGFPTIP TCCGACTTCCACCGAGGAAGGTAGCCCGGCTGG

LSRLFDNAMLRAHRLH CTCTCCAACTTCTACTGAAGAAGGTAGCCCGGC

QLAFDTYQEFEEAYIPK AGGCTCTCCGACCTCTACTGAGGAAGGTACTTC

EQKYSFLQNPQTSLCFS TGAAAGCGCAACCCCGGAGTCCGGCCCAGGTA

ESIPTP SNREETQQKSNL CCTCTACCGAACCGTCTGAGGGCAGCGCACCAG

ELLPJSLLLIQSWLEPVQ GTACCTCTGAAAGCGCAACTCCTGAGTCTGGCC

FLRS VF ANSL VYG ASD S CAGGTAGCGAACCTGCTACCTCCGGCTCTGAGA

NVYDLLKDLEEGIQTL CTCCAGGTACCTCTGAAAGCGCAACCCCGGAAT

MGRLEDGSPRTGQIFK CTGGTCCAGGTAGCGAACCTGCAACCTCTGGCT h(; i i- SEQ SEQ

Q rYSKFDTNSHNDDAL CTGAA LACCCCAGGTACCTCTGAAAGCGCT ACTC

LB :NYGLLYCFRKDMD CTGA^ LTCTGGCCCAGGTACTTCTACTGAA CCGT I ETFLRIVQCRSVEGS CCGAC iGGCAGCGCACCAGGTAGCCCTGCl ^{^}GGCT C( iF CTCCA ACCTCCACCGAAGAAGGTACCTCT GAAA GCGC^ ^ACCCCTGAATCCGGCCCAGGTAGC :GAA

CCGGC AACCTCCGGTTCTGAAACCCCAGG TACT TCTGA AAGCGCTACTCCTGAGTCCGGCCC AGGT AGCCC GGCTGGCTCTCCGACTTCCACCGA GGAA GGTAC ICCCGGCTGGCTCTCCAACTTCTAC rGAA

GAAG( JTACTTCTACCGAACCTTCCGAGGG CAGC GCACC AGGTACTTCTGAAAGCGCTACCCC TGAG TCCGC RCCCAGGTACTTCTGAAAGCGCTAC TCCT GAATC CGGTCCAGGTACTTCTGAAAGCGC TACC CCGG^ UVTCTGGCCCAGGTAGCGAACCGGC TACT TCTGG RTTCTGAAACCCCAGGTAGCGAACC GGCT ACCTC CGGTTCTGAAACTCCAGGT AGCCC AGCA GGCTC :TCCGACTTCCACTGAGGAAGGTAC TTCT ACTG^ LACCTTCCGAAGGCAGCGCACCAGC iTACC TCTAC TGAACCTTCTGAGGGCAGCGCTCC AGGT AGCG^ ^LACCTGCAACCTCTGGCTCTGAAAC CCCA GGTAC CTCTGAAAGCGCTACTCCTGAATC TGGC CCAGC ITACTTCTACTGAACCGTCCGAGGG CAGC GCACC AGGTTTTCCGACTATTCCGCTGTCI GTC TGTTT GATAATGCTATGCTGCGTGCGCACI GTC TGCAC :CAGCTGGCCTTTGATACTTACCAG< 3AAT TTGA^ LGAAGCCTACATTCCTAAAGAGCAG AAGT ACTCT TTCCTGCAAAACCCACAGACTTCT( :TCTG CTTCA GCGAATCTATTCCGACGCCTTCCA VTCG CGAGC JAAACTCAGCAAAAGTCCAATCTGC JAAC TACTC CGCATTTCTCTGCTTCTGATTCAGA GCTG GCTAC iAACCAGTGCAATTTCTGCGTTCCG TCTT

CGCC^ LATAGCCTAGTTTATGGCGCATCCG ACAG CAACC iTATACGATCTCCTGAAAGATCTCG AGGA AGGC^ ^LTTCAGACCCTGATGGGTCGTCTCG AGGA TGGCl CTCCGCGTACTGGTCAGATCTTCA GCA

GACTl ACTCT AAATTTGAT ACT AACAGCC \CAA TGACC iATGCGCTTCTAAAAAACTATGGTC TGCT GTATT GTTTTCGTAAAGATATGGACAAAG TTGA AACCl TCCTGCGTATTGTTCAGTGTCGTTC CGTT GAGG( JCAGCTGTGGTTTCTAA

AE912- AI iPAGSPTSTEEGTPGS 5 ATGGC TGAACCTGCTGGCTCTCCAACCTC⁽ 2 ACT 11 hGH- Gl rASSSPGSSTPSGATG GAGG^ AGGTACCCCGGGTAGCGGTACTG( :TTCT AE288 SP GASPGTSSTGSPGSP TCCTC TCCAGGTAGCTCTACCCCTTCTGG1 OCAA

A( JSPTSTEEGTSESATP CCGGC TCTCCAGGTGCTTCTCCGGGCACC \GCT ES GPGTSTEPSEGSAPG CTACC GGTTCTCCAGGTAGCCCGGCTGGC TCTC SP AGSPTSTEEGTSTEPS CTACC TCTACTGAGGAAGGTACTTCTGAA AGCG EC iSAPGTSTEPSEGSAP

Gl rSESATPESGPGSEPA AACCC ITCCGAAGGTAGCGCTCCAGGTAGC CCA TS GSETPGSEPATSGSET GCAGC ICTCTCCGACTTCCACTGAGGAAGG rTACT PC iSPAGSPTSTEEGTSES TCTAC TGAACCTTCCGAAGGCAGCGCACC AGGT ΑΊ [PESGPGTSTEPSEGS ACCTC TACTGAACCTTCTGAGGGCAGCGC TCCA AI >GTSTEPSEGSAPGSP GGTAC TTCTGAAAGCGCTACCCCGGAATC TGGC A( JSPTSTEEGTSTEPSE CCAGC ITAGCGAACCGGCTACTTCTGGTTC TGAA Gi JAPGTSTEPSEGSAPG ACCCC :AGGTAGCGAACCGGCTACCTCCGC iTTCT TS ESATPESGPGTSTEPS GAAAC ;TCCAGGTAGCCCGGCAGGCTCTCC GACC EC iSAPGTSESATPESGP TCTAC TGAGGAAGGTACTTCTGAAAGCGC AACC liGH 1I<3 MM.

ΧΊ^'Γ.Ν Amino Sl'(|I 'IKT ID Nuck-olirii- SI-(|I -IKT II)

Nii iiK'" ii NO

GSEPATSGSETPGTSTEP CCGGAGTCCGGCCCAGGTACCTCTACCGAACCG

SEGSAPGTSTEPSEGSA TCTGAGGGCAGCGCACCAGGTACTTCTACCGAA

PGTSESATPESGPGTSES CCGTCCGAGGGTAGCGCACCAGGTAGCCCAGC

ATPESGPGSPAGSPTST AGGTTCTCCTACCTCCACCGAGGAAGGTACTTC

EEGTSESATPESGPGSEP TACCGAACCGTCCGAGGGTAGCGCACCAGGTA

ATSGSETPGTSESATPES CCTCTACTGAACCTTCTGAGGGCAGCGCTCCAG

GPGTSTEPSEGSAPGTS GTACTTCTGAAAGCGCTACCCCGGAGTCCGGTC

TEPSEGSAPGTSTEPSEG CAGGTACTTCTACTGAACCGTCCGAAGGTAGCG

SAPGTSTEPSEGSAPGT CACCAGGTACTTCTGAAAGCGCAACCCCTGAAT

STEPSEGSAPGTSTEPSE CCGGTCCAGGTAGCGAACCGGCTACTTCTGGCT

GSAPGSPAGSPTSTEEG CTGAGACTCCAGGTACTTCTACCGAACCGTCCG

TSTEPSEGSAPGTSESAT AAGGTAGCGCACCAGGTACTTCTACTGAACCGT

PESGPGSEPATSGSETP CTGAAGGTAGCGCACCAGGTACTTCTGAAAGCG

GTSESATPESGPGSEPA CAACCCCGGAATCCGGCCCAGGTACCTCTGAAA

TSGSETPGTSESATPESG GCGCAACCCCGGAGTCCGGCCCAGGTAGCCCTG

PGTSTEPSEGSAPGTSES CTGGCTCTCCAACCTCCACCGAAGAAGGTACCT

ATPESGPGSPAGSPTST CTGAAAGCGCAACCCCTGAATCCGGCCCAGGTA

EEGSPAGSPTSTEEGSP GCGAACCGGCAACCTCCGGTTCTGAAACCCCAG

AGSPTSTEEGTSESATP GTACCTCTGAAAGCGCTACTCCGGAGTCTGGCC

ESGPGTSTEPSEGSAPG CAGGTACCTCTACTGAACCGTCTGAGGGTAGCG

TSESATPESGPGSEPATS CTCCAGGTACTTCTACTGAACCGTCCGAAGGTA

GSETPGTSESATPESGP GCGCACCAGGTACTTCTACCGAACCGTCCGAAG

GSEPATSGSETPGTSES GCAGCGCTCCAGGTACCTCTACTGAACCTTCCG

ATPESGPGTSTEPSEGS AGGGCAGCGCTCCAGGTACCTCTACCGAACCTT

APGSPAGSPTSTEEGTS CTGAAGGTAGCGCACCAGGTACTTCTACCGAAC

ESATPESGPGSEPATSG CGTCCGAGGGTAGCGCACCAGGTAGCCCAGCA

SETPGTSESATPESGPGS GGTTCTCCTACCTCCACCGAGGAAGGTACTTCT

PAGSPTSTEEGSPAGSP ACCGAACCGTCCGAGGGTAGCGCACCAGGTAC

TSTEEGTSTEPSEGSAP CTCTGAAAGCGCAACTCCTGAGTCTGGCCCAGG

GTSESATPESGPGTSES TAGCGAACCTGCTACCTCCGGCTCTGAGACTCC

ATPESGPGTSESATPES AGGTACCTCTGAAAGCGCAACCCCGGAATCTGG

GPGSEPATSGSETPGSE TCCAGGTAGCGAACCTGCAACCTCTGGCTCTGA

PATSGSETPGSPAGSPTS AACCCCAGGTACCTCTGAAAGCGCTACTCCTGA

TEEGTSTEPSEGSAPGT ATCTGGCCCAGGTACTTCTACTGAACCGTCCGA

STEPSEGSAPGSEPATS GGGCAGCGCACCAGGTACTTCTGAAAGCGCTAC

GSETPGTSESATPESGP TCCTGAGTCCGGCCCAGGTAGCCCGGCTGGCTC

GTSTEPSEGSAPGFPTIP TCCGACTTCCACCGAGGAAGGTAGCCCGGCTGG

LSRLFDNAMLRAHRLH CTCTCCAACTTCTACTGAAGAAGGTAGCCCGGC

QLAFDTYQEFEEAYIPK AGGCTCTCCGACCTCTACTGAGGAAGGTACTTC

EQKYSFLQNPQTSLCFS TGAAAGCGCAACCCCGGAGTCCGGCCCAGGTA

ESIPTP SNREETQQKSNL CCTCTACCGAACCGTCTGAGGGCAGCGCACCAG

ELLPJSLLLIQSWLEPVQ GTACCTCTGAAAGCGCAACTCCTGAGTCTGGCC

FLRS VF ANSL VYG ASD S CAGGTAGCGAACCTGCTACCTCCGGCTCTGAGA

NVYDLLKDLEEGIQTL CTCCAGGTACCTCTGAAAGCGCAACCCCGGAAT

MGRLEDGSPRTGQIFK CTGGTCCAGGTAGCGAACCTGCAACCTCTGGCT

QTYSKFDTNSHNDDAL CTGAAACCCCAGGTACCTCTGAAAGCGCTACTC

LKNYGLLYCFRKDMD CTGAATCTGGCCCAGGTACTTCTACTGAACCGT

KVETFLRIVQCRSVEGS CCGAGGGCAGCGCACCAGGTAGCCCTGCTGGCT

CGFGGTSESATPESGPG CTCCAACCTCCACCGAAGAAGGTACCTCTGAAA

SEPATSGSETPGTSESAT GCGCAACCCCTGAATCCGGCCCAGGTAGCGAA

PESGPGSEPATSGSETP CCGGCAACCTCCGGTTCTGAAACCCCAGGTACT

GTSESATPESGPGTSTEP TCTGAAAGCGCTACTCCTGAGTCCGGCCCAGGT

SEGSAPGSPAGSPTSTE AGCCCGGCTGGCTCTCCGACTTCCACCGAGGAA

EGTSESATPESGPGSEP GGTAGCCCGGCTGGCTCTCCAACTTCTACTGAA

ATSGSETPGTSESATPES GAAGGTACTTCTACCGAACCTTCCGAGGGCAGC

GPGSPAGSPTSTEEGSP GCACCAGGTACTTCTGAAAGCGCTACCCCTGAG

AGSPTSTEEGTSTEPSE TCCGGCCCAGGTACTTCTGAAAGCGCTACTCCT

liGH 1I<3 MM.

ΧΊ^'Γ.Ν Amino Sl'(|I 'IKT ID Nuck-olirii- SI-(|I -IKT II)

Nii iiK'" ii NO

EGSTSSTAESPGPGTSTP ACCCCAGGTAGCCCAGCAGGTTCTCCAACTTCT

ESGSASPGSTSESPSGTA ACTGAAGAAGGTTCTACCAGCTCTACCGCAGAA

PGSTSESPSGTAPGTSTP TCTCCTGGTCCAGGTACCTCTACTCCGGAAAGC

ESGSASPGTSTPESGSAS GGCTCTGCATCTCCAGGTTCTACTAGCGAATCT

PGSEPATSGSETPGTSES CCTTCTGGCACTGCACCAGGTTCTACTAGCGAA

ATPESGPGSPAGSPTST TCCCCGTCTGGTACTGCTCCAGGTACTTCTACTC

EEGTSTEPSEGSAPGTS CTGAAAGCGGTTCCGCTTCTCCAGGTACCTCTA

ESATPESGPGTSTEPSEG CTCCGGAAAGCGGTTCTGCATCTCCAGGTAGCG

SAPGTSTEPSEGSAPGSP AACCGGCAACCTCCGGCTCTGAAACCCCAGGTA

AGSPTSTEEGTSTEPSE CCTCTGAAAGCGCTACTCCTGAATCCGGCCCAG

GSAPGTSTEPSEGSAPG GTAGCCCGGCAGGTTCTCCGACTTCCACTGAGG

TSESATPESGPGTSESAT AAGGTACCTCTACTGAACCTTCTGAGGGCAGCG

PESGPGTSTEPSEGSAP CTCCAGGTACTTCTGAAAGCGCTACCCCGGAGT

GTSTEPSEGSAPGTSES CCGGTCCAGGTACTTCTACTGAACCGTCCGAAG

ATPESGPGTSTEPSEGS GTAGCGCACCAGGTACTTCTACCGAACCGTCCG

APGSEPATSGSETPGSP AGGGTAGCGCACCAGGTAGCCCAGCAGGTTCTC

AGSPTSTEEGSSTPSGA CTACCTCCACCGAGGAAGGTACTTCTACCGAAC

TGSPGTPGSGTASSSPG CGTCCGAGGGTAGCGCACCAGGTACTTCTACCG

SSTPSGATGSPGTSTEPS AACCTTCCGAGGGCAGCGCACCAGGTACTTCTG

EGSAPGTSTEPSEGSAP AAAGCGCTACCCCTGAGTCCGGCCCAGGTACTT

GSEPATSGSETPGSPAG CTGAAAGCGCTACTCCTGAATCCGGTCCAGGTA

SPTSTEEGSPAGSPTSTE CCTCTACTGAACCTTCCGAAGGCAGCGCTCCAG

EGTSTEPSEGSAPGASA GTACCTCTACCGAACCGTCCGAGGGCAGCGCAC

SGAPSTGGTSESATPES CAGGTACTTCTGAAAGCGCAACCCCTGAATCCG

GPGSPAGSPTSTEEGSP GTCCAGGTACTTCTACTGAACCTTCCGAAGGTA

AGSPTSTEEGSTSSTAES GCGCTCCAGGTAGCGAACCTGCTACTTCTGGTT

PGPGSTSESPSGTAPGTS CTGAAACCCCAGGTAGCCCGGCTGGCTCTCCGA

PSGESSTAPGTPGSGTA CCTCCACCGAGGAAGGTAGCTCTACCCCGTCTG

SSSPGSSTPSGATGSPGS GTGCTACTGGTTCTCCAGGTACTCCGGGCAGCG

SPSASTGTGPGSEPATS GTACTGCTTCTTCCTCTCCAGGTAGCTCTACCCC

GSETPGTSESATPESGP TTCTGGTGCTACTGGCTCTCCAGGTACCTCTACC

GSEPATSGSETPGSTSST GAACCGTCCGAGGGTAGCGCACCAGGTACCTCT

AESPGPGSTSSTAESPGP ACTGAACCGTCTGAGGGTAGCGCTCCAGGTAGC

GTSPSGESSTAPGSEPA GAACCGGCAACCTCCGGTTCTGAAACTCCAGGT

TSGSETPGSEPATSGSET AGCCCTGCTGGCTCTCCGACTTCTACTGAGGAA

PGTSTEPSEGSAPGSTSS GGTAGCCCGGCTGGTTCTCCGACTTCTACTGAG

TAESPGPGTSTPESGSA GAAGGTACTTCTACCGAACCTTCCGAAGGTAGC

SPGSTSESPSGTAPGTST GCTCCAGGTGCAAGCGCAAGCGGCGCGCCAAG

EPSEGSAPGTSTEPSEGS CACGGGAGGTACTTCTGAAAGCGCTACTCCTGA

APGTSTEPSEGSAPGSS GTCCGGCCCAGGTAGCCCGGCTGGCTCTCCGAC

TPSGATGSPGSSPSAST TTCCACCGAGGAAGGTAGCCCGGCTGGCTCTCC

GTGPGASPGTSSTGSPG AACTTCTACTGAAGAAGGTTCTACCAGCTCTAC

SEPATSGSETPGTSESAT CGCTGAATCTCCTGGCCCAGGTTCTACTAGCGA

PESGPGSPAGSPTSTEE ATCTCCGTCTGGCACCGCACCAGGTACTTCCCC

GSSTPSGATGSPGSSPS TAGCGGTGAATCTTCTACTGCACCAGGTACCCC

ASTGTGPGASPGTSSTG TGGCAGCGGTACCGCTTCTTCCTCTCCAGGTAG

SPGTSESATPESGPGTST CTCTACCCCGTCTGGTGCTACTGGCTCTCCAGGT

EPSEGSAPGTSTEPSEGS TCTAGCCCGTCTGCATCTACCGGTACCGGCCCA

APGFPTIPLSRLFDNAM GGTAGCGAACCGGCAACCTCCGGCTCTGAAACT

LRAHRLHQLAFDTYQE CCAGGTACTTCTGAAAGCGCTACTCCGGAATCC

FEEAYIPKEQKYSFLQN GGCCCAGGTAGCGAACCGGCTACTTCCGGCTCT

PQTSLCFSESIPTPSNRE GAAACCCCAGGTTCCACCAGCTCTACTGCAGAA

ETQQKSNLELLPJSLLLI TCTCCGGGCCCAGGTTCTACTAGCTCTACTGCA

QSWLEPVQFLRSVFAN GAATCTCCGGGTCCAGGTACTTCTCCTAGCGGC

SL VYG ASD SNVYDLLK GAATCTTCTACCGCTCCAGGTAGCGAACCGGCA

DLEEGIQTLMGRLEDGS ACCTCTGGCTCTGAAACTCCAGGTAGCGAACCT

PRTGQIFKQTYSKFDTN GCAACCTCCGGCTCTGAAACCCCAGGTACTTCT

Further characterization of the exemplary hGH-XTEN fusion proteins provided in Table 1 can be found in the examples (e.g., Examples 27-35) of Schellenberger et al.

WO10/144502A2, which is incorporated herein by reference in its entirety.

In some embodiments, methods described herein contemplate use of hGH-XTEN fusion proteins comprising one of the amino acid sequences shown in FIG. 1, Table 1, or as described in Schellenberger et al. WO10/144502A2 (which is incorporated herein by reference in its entirety). In addition, pharmacologically active variants of any of the hGH- XTEN fusion proteins described and referred to herein are also contemplated. As described more fully below, the fusion proteins optionally include spacer sequences that further comprise cleavage sequences to release the GH from the fusion protein when acted on by a protease, releasing GH from the XTEN sequence(s).

In one aspect, the disclosure provides an isolated fusion protein comprising at least a first biologically active growth hormone protein covalently linked to one or more extended recombinant polypeptides ("XTEN"), resulting in a growth hormone-XTEN fusion protein composition (hereinafter "hGH-XTEN"). In one embodiment, the growth hormone is human growth hormone or a sequence variant of hGH. As described more fully below, the fusion proteins optionally include spacer sequences that further comprise cleavage sequences to release the GH from the fusion protein when acted on by a protease.

The term "hGH-XTEN", as used herein, is meant to encompass fusion polypeptides that comprise a payload region comprising a biologically active GH that mediates one or more biological or therapeutic activities associated with growth hormone and at least one other region comprising at least a first XTEN polypeptide that serves as a carrier. In one embodiment, the disclosure provides an hGH-XTEN fusion protein comprising the sequence set forth in Table 1.

The GH of the subject compositions, together with their corresponding nucleic acid and amino acid sequences, are well known in the art and descriptions and sequences are available in public databases such as Chemical Abstracts Services Databases (e.g., the CAS Registry), GenBank, The Universal Protein Resource (UniProt) and subscription provided databases such as GenSeq (e.g., Derwent). Polynucleotide sequences may be a wild type polynucleotide sequence encoding a given GH (e.g., either full length or mature), or in some instances the sequence may be a variant of the wild type polynucleotide sequence (e.g., a polynucleotide which encodes the wild type biologically active protein, wherein the DNA sequence of the polynucleotide has been optimized, for example, for expression in a particular species; or a polynucleotide encoding a variant of the wild type protein, such as a site directed mutant or an allelic variant. It is well within the ability of the skilled artisan to use a wild-type or consensus cDNA sequence or a codon-optimized variant of a GH to create fusion protein constructs contemplated by the invention using methods known in the art and/or in conjunction with the guidance and methods provided herein, and described more fully in the Examples of Schellenberger et al. WO10/144502A2 which is incorporated herein by reference in its entirety.

The GH for inclusion in a hGH-XTEN of the present disclosure includes any growth hormone or sequence variant of biologic, therapeutic, prophylactic, or diagnostic interest or function, or that is useful for mediating or preventing or ameliorating a disease, disorder or condition associated with growth, growth hormone deficiency or defect when administered to a pediatric subject. Of particular interest are hGH-XTEN fusion protein compositions for which an increase in a pharmacokinetic parameter, increased solubility, increased stability, or some other enhanced pharmaceutical or pharmacodynamic property compared to native GH is sought, or for which increasing the terminal half-life would improve efficacy, safety, or result in reduce dosing frequency and/or improve pediatric patient compliance. Thus, the hGH-XTEN fusion protein compositions are prepared with various objectives in mind, including improving the therapeutic efficacy of the bioactive GH by, for example, increasing the in vivo exposure or the length that the hGH-XTEN remains within the therapeutic window when administered to a pediatric subject, compared to a GH not linked to XTEN.

In one embodiment, the GH incorporated into the subject compositions can be a recombinant polypeptide with a sequence corresponding to a protein found in nature, such as human growth hormone. In one embodiment, the GH is human GH comprising the following amino acid sequence:

FPTIPLSRLFDNAMLRAHRLHQLAFDTYQEFEEAYIPKEQKYSFLQNPQTSLCFSESIP TPSNREETQQKSNLELLRISLLLIQSWLEPVQFLRSVFANSLVYGASDSNVYDLLKDL EEGIQTLMGRLEDGSPRTGQIFKQTYSKFDTNSHNDDALLKNYGLLYCFRKDMDKV ETFLRIVQCRSVEGSCGF (SEQ ID NO:41).

In another embodiment, the GH is a sequence variant, fragment, homolog, or mimetic of a natural sequence that retain at least a portion of the biological activity of the native GH. In non-limiting examples, a GH is a sequence that exhibits at least about 80% sequence identity, or alternatively 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or at least about 99%, or 100% sequence identity to the protein sequence of SEQ ID NO:41. In one embodiment, the hGH-XTEN fusion protein comprises a single GH molecule linked to an XTEN (as described more fully below). In another embodiment, the hGH-XTEN fusion protein comprises a single GH molecule linked to a first and a second XTEN, with an N- to C-terminus configuration of XTEN-GH-XTEN, in which the GH is a sequence that exhibits at least about 80% sequence identity, or alternatively 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%,

94%, 95%, 96%, 97%, 98%, or at least about 99%, or 100% sequence identity to the human growth hormone protein sequence (SEQ ID NO:41), and the first and/or the second XTEN are sequences that exhibits at least about 80% sequence identity, or alternatively 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or at least about 99%, or 100% sequence identity to a sequence selected from Table 2.

In general, the GH fusion partner component of the hGH-XTEN exhibits a binding specificity to a given target or another desired biological characteristic when used in vivo or when utilized in an in vitro assay. For example, the hGH-XTEN is an agonist, having the ability to bind to a transmembrane receptor for growth hormone. In one embodiment, the binding of hGH-XTEN to growth receptor leads to receptor dimerization and lead to at least a portion of the activation of intercellular signal transduction pathway compared to native growth hormone. In one embodiment, the hGH-XTEN bound to a transmembrane receptor for growth hormone would exhibit at least about 1%, or about 5%, or about 10%, or about

15%, or about 20%, or about 25%, or about 30%, or about 40%, or about 50%, or about 60%, or about 70%, or about 80%, or about 90%, or at least about 95% of the activation of intercellular signal transduction pathway compared to native growth hormone not linked to XTEN.

In some embodiments, the subject hGH-XTEN of the present disclosure exhibits an enhancement of one or more pharmacokinetic or pharmacodynamic parameters, which optionally is enhanced by release of GH from the fusion protein by cleavage of a spacer sequence. The hGH-XTEN with enhanced pharmacokinetic parameters permits less frequent dosing or an enhanced pharmacologic effect, such as but not limited to maintaining the biologically active hGH-XTEN within the therapeutic window between the minimum effective dose or blood concentration (Cmin) and the maximum tolerated dose or blood concentration (Cmax). In addition, the hGH-XTEN with enhanced pharmacodynamic parameters permits lower and/or less frequent dosing or an enhanced pharmacodynamic effect, such as but not limited to a sustained or normalized IGF-I standard deviation score (IGF-I SDS). In such cases, the linking of the GH to a fusion protein comprising a select XTEN sequence(s) can result in an improvement in these properties, making them more useful as therapeutic or preventive agents compared to GH not linked to XTEN.

IV). XTENDED RECOMBINANT POLYPEPTIDES

The present disclosure provides, in some embodiments, an improved therapeutic regimen for PGHD therapy. In some embodiments, the present disclosure provides methods for bolus dose administration of a human growth hormone-XTEN (hGH-XTEN) fusion protein to a pediatric patient with PGHD. Accordingly, in one aspect, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) with a hGH-XTEN recombinant polypeptide or fusion protein. In one aspect, the present disclosure provides XTEN polypeptide compositions that are useful as a fusion protein partner to which GH is linked, resulting in a hGH-XTEN fusion protein. As provided herein, XTENs are generally extended length polypeptides with non- naturally occurring, substantially non-repetitive sequences that are composed mainly of small hydrophilic amino acids, with the sequence having a low degree or no secondary or tertiary structure under physiologic conditions.

XTENs have utility as a fusion protein partners in that they serve as a "carrier", conferring certain desirable pharmacokinetic, physicochemical and pharmaceutical properties when linked to a GH protein to a create a fusion protein. Such desirable properties include but are not limited to enhanced pharmacokinetic parameters and solubility characteristics the compositions, amongst other properties described herein. Such fusion protein compositions have utility to treat certain growth hormone-related diseases, disorders or conditions, as described herein. As used herein, "XTEN" specifically excludes antibodies or antibody fragments such as single-chain antibodies or Fc fragments of a light chain or a heavy chain.

In some embodiments, XTEN are long polypeptides having greater than about 100 to about 3000 amino acid residues, preferably greater than 400 to about 3000 residues when used as a carrier or cumulatively when more than one XTEN unit is used in a single fusion protein. In other embodiments, when used as a linker between fusion protein components or where an increase in half-life of the fusion protein is not needed but where an increase in solubility or other physico/chemical property for the GH fusion partner component is desired, an XTEN sequence shorter than 100 amino acid residues, such as about 96, or about 84, or about 72, or about 60, or about 48, or about 36 amino acid residues are incorporated into a fusion protein composition with the GH to effect the property.

The selection criteria for the XTEN to be linked to the biologically active proteins used to create the inventive fusion proteins compositions generally relate to attributes of physical/chemical properties and conformational structure of the XTEN that is, in turn, used to confer enhanced pharmaceutical and pharmacokinetic properties to the fusion proteins. In some embodiments, the XTENs described herein exhibit one or more of the following advantageous properties: conformational flexibility, enhanced aqueous solubility, high degree of protease resistance, low immunogenicity, low binding to mammalian receptors, and increased hydrodynamic (or Stokes) radii; properties that make them particularly useful as fusion protein partners. Non-limiting examples of the properties of the fusion proteins comprising GH that is enhanced by XTEN include increases in the overall solubility and/or metabolic stability, reduced susceptibility to proteolysis, reduced immunogenicity, reduced rate of absorption when administered subcutaneously or intramuscularly, and enhanced pharmacokinetic properties such as longer terminal half-life and increased area under the curve (AUC), slower absorption after subcutaneous or intramuscular injection (compared to GH not linked to XTEN and administered by a similar route) such that the Cmax is lower, which, in turn, results in reductions in adverse effects of the GH that, collectively, results in an increased period of time that a fusion protein of a hGH-XTEN composition administered to a pediatric patient retains therapeutic activity.

1. Non-repetitive Sequences

In some embodiments, XTEN sequences of the compositions are substantially non- repetitive. In general, repetitive amino acid sequences have a tendency to aggregate or form higher order structures, as exemplified by natural repetitive sequences such as collagens and leucine zippers, or form contacts resulting in crystalline or pseudocrystaline structures. In contrast, the low tendency of non-repetitive sequences to aggregate enables the design of long-sequence XTENs with a relatively low frequency of charged amino acids that would be likely to aggregate if the sequences were otherwise repetitive. Typically, the hGH-XTEN fusion proteins comprise XTEN sequences of greater than about 100 to about 3000 amino acid residues, preferably greater than 400 to about 3000 cumulative residues, wherein the sequences are substantially non-repetitive. In one embodiment, the XTEN sequences have greater than about 100 to about 3000 amino acid residues, preferably greater than 400 to about 3000 amino acid residues, in which no three contiguous amino acids in the sequence are identical amino acid types unless the amino acid is serine, in which case no more than three contiguous amino acids are serine residues. In the foregoing embodiment, the XTEN sequence would be substantially non-repetitive.

The degree of repetitiveness of a polypeptide or a gene are measured by computer programs or algorithms or by other means known in the art, including subsequence scores (see Example 44 of Schellenberger et al. WO10/144502A2; Cleland et al. U.S. 13/829,369; and Cleland et al. W013/184216, each of which is incorporated herein by reference in its entirety). In some embodiments, the present invention provides hGH-XTEN each comprising one or more XTEN in which the XTEN have a subsequence score less than 12, more preferably less than 10, more preferably less than 9, more preferably less than 8, more preferably less than 7, more preferably less than 6, and most preferably less than 5. In the embodiments hereinabove described in this paragraph, an XTEN with a subsequence score less than about 10 (i.e., 9, 8, 7, etc.) is "substantially non-repetitive." The non-repetitive characteristic of XTEN impart to fusion proteins with GH a greater degree of solubility and less tendency to aggregate compared to polypeptides having repetitive sequences. These properties facilitate the formulation of XTEN-comprising pharmaceutical preparations containing extremely high drug concentrations, in some cases exceeding 100 mg/ml.

2. Exemplary Sequence Motifs

In some embodiments, the XTEN comprises multiple units of shorter sequences, or motifs, in which the amino acid sequences of the motifs are non-repetitive. In designing XTEN sequences, it was discovered that the non-repetitive criterion may be met despite the use of a "building block" approach using a library of sequence motifs that are multimerized to create the XTEN sequences. Thus, while an XTEN sequence may consist of multiple units of as few as four different types of sequence motifs, because the motifs themselves generally consist of non-repetitive amino acid sequences, the overall XTEN sequence is rendered substantially non-repetitive (see Schellenberger et al. WO10/144502A2; Cleland et al. U.S. 13/829,369; and Cleland et al. W013/184216, each of which is incorporated herein by reference in its entirety).

3. Length of Sequence

In one aspect, the present disclosure, provides hGH-XTEN compositions comprising carriers of XTEN polypeptides with extended length sequences, (see Schellenberger et al. WO10/144502A2; Cleland et al. U.S. 13/829,369; and Cleland et al. PCT/US2013/031673, each of which is incorporated herein by reference in its entirety) Non-limiting examples of XTEN contemplated for inclusion in the hGH-XTEN described herein are presented in Table 2. In one embodiment, the present disclosure provides hGH-XTEN compositions wherein the XTEN sequence length of the fusion protein(s) is greater than about 100 to about 3000 amino acid residues, and in some cases is greater than 400 to about 3000 amino acid residues, wherein the XTEN confers enhanced pharmacokinetic properties on the hGH-XTEN in comparison to GH not linked to XTEN. In some embodiments, the XTEN sequences of the hGH-XTEN compositions described herein can be about 100, or about 144, or about 288, or about 401, or about 500, or about 600, or about 700, or about 800, or about 900, or about 1000, or about 1500, or about 2000, or about 2500 or up to about 3000 amino acid residues in length. In other cases, the XTEN sequences can be about 100 to 150, about 150 to 250, about 250 to 400, 401 to about 500, about 500 to 900, about 900 to 1500, about 1500 to 2000, or about 2000 to about 3000 amino acid residues in length. In one embodiment, the hGH- XTEN comprises an XTEN sequence that exhibits at least about 80% sequence identity, or alternatively 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% sequence identity to a XTEN selected from Table 2. In some embodiments, the XTEN sequence is designed for optimized expression as the N- terminal component of the hGH-XTEN by inclusion of encoding nucleotides for an optimized N-terminal leader sequence (NTS) in the XTEN portion of the gene encoding the fusion protein. In another embodiment, the N-terminal XTEN sequence of the expressed hGH- XTEN has at least 90% sequence identity to any sequence selected from Table 2. In one embodiment, the N-terminal XTEN sequence of the expressed hGH-XTEN has at least 90% sequence identity to the sequence of AE48 or AM48, AE624, AE911, AE912 or AM923.

In other embodiments, the hGH-XTEN fusion protein comprises a first and a second

XTEN sequence, wherein the cumulative total of the residues in the XTEN sequences is greater than about 400 to about 3000 amino acid residues. In embodiments of the foregoing, the hGH-XTEN fusion protein comprises a first and a second XTEN sequence wherein the sequences each exhibit at least about 80% sequence identity, or alternatively 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100%) sequence identity to at least a first or additionally a second XTEN selected from Table 2. Examples where more than one XTEN is used in a hGH-XTEN composition include, but are not limited to constructs with an XTEN linked to both the N- and C-termini of at least one GH.

As described more fully below, the invention provides methods in which the hGH-

XTEN is designed by selecting the length of the XTEN to confer a target half-life on a fusion protein administered to a pediatric subject. In general, XTEN lengths longer that about cumulative 400 residues incorporated into the hGH-XTEN compositions result in longer half- life compared to shorter cumulative lengths; e.g., shorter than about 280 residues. However, in another embodiment, hGH-XTEN fusion proteins are designed to comprise XTEN with a longer sequence length that is selected to additionally confer slower rates of systemic absorption after subcutaneous or intramuscular administration to a pediatric subject. In such embodiments, the Cmax is reduced in comparison to a comparable dose of a GH not linked to XTEN, thereby contributing to the ability to keep the hGH-XTEN within the therapeutic window for the composition. Thus, the XTEN confers the property of a depot to the administered hGH-XTEN, in addition to the other physical/chemical properties described herein. Table 2: XTEN Polypeptides

si o

XTEN

II) A ini ii 1 Aci d SL\|I i i' in.- i

Niiim-

NO:

AE48 13 MAEPAGSP^r rSTEEGTPGSGTASSSPGSSTPSGATGSPGASPGTSSTGS

AM48 14 MAEPAGSP^r rSTEEGASPGTSSTGSPGSSTPSGATGSPGSSTPSGATGS

AE144 15 GSEPATSGS ETPGTSESATPESGPGSEPATSGSETPGSPAGSPTSTEEGTSTEPSEGS

APGSEPATS GSETPGSEPATSGSETPGSEPATSGSETPGTSTEPSEGSAPGTSESATP ESGPGSEPA TSGSETPGTSTEPSEGSAP

AF144 16 GTSTPESGS ASPGTSPSGESSTAPGTSPSGESSTAPGSTSSTAESPGPGSTSESPSGTA

PGSTSSTAE SPGPGTSPSGESSTAPGTSTPESGSASPGSTSSTAESPGPGTSPSGESST APGTSPSGE SSTAPGTSPSGESSTAP

AE288 17 GTSESATPE SGPGSEPATSGSETPGTSESATPESGPGSEPATSGSETPGTSESATPES

GPGTSTEPS EGSAPGSPAGSPTSTEEGTSESATPESGPGSEPATSGSETPGTSESATP ESGPGSPAC rSPTSTEEGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGTSESA TPESGPGTS ESATPESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTST EPSEGSAPG TSTEPSEGSAPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAP

AF504 18 GASPGTSST GSPGSSPSASTGTGPGSSPSASTGTGPGTPGSGTASSSPGSSTPSGATG

SPGSXPSAS TGTGPGASPGTSSTGSPGTPGSGTASSSPGSSTPSGATGSPGTPGSGT ASSSPGASP GTSSTGSPGASPGTSSTGSPGTPGSGTASSSPGSSTPSGATGSPGASPG TSSTGSPGT PGSGTASSSPGSSTPSGATGSPGSXPSASTGTGPGSSPSASTGTGPGSS TPSGATGSP GSSTPSGATGSPGASPGTSSTGSPGASPGTSSTGSPGASPGTSSTGSPG TPGSGTASS SPGASPGTSSTGSPGASPGTSSTGSPGASPGTSSTGSPGSSPSASTGTG PGTPGSGT^ LSSSPGASPGTSSTGSPGASPGTSSTGSPGASPGTSSTGSPGSSTPSGAT GSPGSSTPS GATGSPGASPGTSSTGSPGTPGSGTASSSPGSSTPSGATGSPGSSTPSG ATGSPGSST PSGATGSPGSSPSASTGTGPGASPGTSSTGSP

AF540 19 GSTSSTAES PGPGSTSSTAESPGPGSTSESPSGTAPGSTSSTAESPGPGSTSSTAESPG

PGTSTPESG SASPGSTSESPSGTAPGTSPSGESSTAPGSTSESPSGTAPGSTSESPSGT APGTSPSGE SSTAPGSTSESPSGTAPGSTSESPSGTAPGTSPSGESSTAPGSTSESPSG TAPGSTSES PSGTAPGSTSESPSGTAPGTSTPESGSASPGSTSESPSGTAPGTSTPESG SASPGSTSS rAESPGPGSTSSTAESPGPGTSTPESGSASPGTSTPESGSASPGSTSESP SGTAPGTSl PESGSASPGTSTPESGSASPGSTSESPSGTAPGSTSESPSGTAPGSTSES PSGTAPGST SSTAESPGPGTSTPESGSASPGTSTPESGSASPGSTSESPSGTAPGSTSE SPSGTAPGT STPESGSASPGSTSESPSGTAPGSTSESPSGTAPGTSTPESGSASPGTSP SGESSTAPG STSSTAESPGPGTSPSGESSTAPGSTSSTAESPGPGTSTPESGSASPGST SESPSGTAP

AD576 20 GSSESGSSE GGPGSGGEPSESGSSGSSESGSSEGGPGSSESGSSEGGPGSSESGSSEG

GPGSSESGS SEGGPGSSESGSSEGGPGESPGGSSGSESGSEGSSGPGESSGSSESGSS EGGPGSSES GSSEGGPGSSESGSSEGGPGSGGEPSESGSSGESPGGSSGSESGESPG GSSGSESGS GGEPSESGSSGSSESGSSEGGPGSGGEPSESGSSGSGGEPSESGSSGSE GSSGPGESS GESPGGSSGSESGSGGEPSESGSSGSGGEPSESGSSGSGGEPSESGSSG SSESGSSEG GPGESPGGSSGSESGESPGGSSGSESGESPGGSSGSESGESPGGSSGSE SGESPGGSS GSESGSSESGSSEGGPGSGGEPSESGSSGSEGSSGPGESSGSSESGSSE GGPGSGGE] ³SESGSSGSSESGSSEGGPGSGGEPSESGSSGESPGGSSGSESGESPGG SSGSESGSS] ESGSSEGGPGSGGEPSESGSSGSSESGSSEGGPGSGGEPSESGSSGSGG EPSESGSSG ESPGGSSGSESGSEGSSGPGESSGSSESGSSEGGPGSEGSSGPGESS

AE576 21 GSPAGSPTS TEEGTSESATPESGPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGS

APGTSTEPS EGSAPGTSESATPESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPT STEEGTSES ATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPS EGSAPGTSl EPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSEPA TSGSETPGT STEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGSP AGSPTSTEE GTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAPG TSTEPSEGS APGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSA PGSPAGSPT STEEGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGTSESATPE SGPGSEPAT SGSETPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSPAGSP TSTEEGSPA GSPTSTEEGSPAGSPTSTEEGTSESATPESGPGTSTEPSEGSAP

AF576 22 GSTSSTAES PGPGSTSSTAESPGPGSTSESPSGTAPGSTSSTAESPGPGSTSSTAESPG

PGTSTPESG SASPGSTSESPSGTAPGTSPSGESSTAPGSTSESPSGTAPGSTSESPSGT SI.O

I .N

I I) Amino Acid Νι-ψιι-ιιΐΐ

Nsi mi- NO:

APGTSPSGESSTAPGSTSESPSGTAPGSTSESPSGTAPGTSPSGESSTAPGSTSESPSG

TAPGSTSESPSGTAPGSTSESPSGTAPGTSTPESGSASPGSTSESPSGTAPGTSTPESG

SASPGSTSSTAESPGPGSTSSTAESPGPGTSTPESGSASPGTSTPESGSASPGSTSESP

SGTAPGTSTPESGSASPGTSTPESGSASPGSTSESPSGTAPGSTSESPSGTAPGSTSES

PSGTAPGSTSSTAESPGPGTSTPESGSASPGTSTPESGSASPGSTSESPSGTAPGSTSE

SPSGTAPGTSTPESGSASPGSTSESPSGTAPGSTSESPSGTAPGTSTPESGSASPGTSP

SGESSTAPGSTSSTAESPGPGTSPSGESSTAPGSTSSTAESPGPGTSTPESGSASPGST

SESPSGTAPGSTSSTAESPGPGTSTPESGSASPGTSTPESGSASP

AE624 23 MAEPAGSPTSTEEGTPGSGTASSSPGSSTPSGATGSPGASPGTSSTGSPGSPAGSPT

STEEGTSESATPESGPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEPS

EGSAPGTSESATPESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSES

ATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTS

TEPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPG

TSTEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGSPAGSPTSTE

EGTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEG

SAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSP

TSTEEGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGSEPA

TSGSETPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSPAGSPTSTEEGSP

AGSPTSTEEGSPAGSPTSTEEGTSESATPESGPGTSTEPSEGSAP

AD836 24 GSSESGSSEGGPGSSESGSSEGGPGESPGGSSGSESGSGGEPSESGSSGESPGGSSGS

ESGESPGGSSGSESGSSESGSSEGGPGSSESGSSEGGPGSSESGSSEGGPGESPGGSS

GSESGESPGGSSGSESGESPGGSSGSESGSSESGSSEGGPGSSESGSSEGGPGSSESG

SSEGGPGSSESGSSEGGPGSSESGSSEGGPGSSESGSSEGGPGSGGEPSESGSSGESP

GGSSGSESGESPGGSSGSESGSGGEPSESGSSGSEGSSGPGESSGSSESGSSEGGPGS

GGEPSESGSSGSEGSSGPGESSGSSESGSSEGGPGSGGEPSESGSSGESPGGSSGSES

GSGGEPSESGSSGSGGEPSESGSSGSSESGSSEGGPGSGGEPSESGSSGSGGEPSESG

SSGSEGSSGPGESSGESPGGSSGSESGSEGSSGPGESSGSEGSSGPGESSGSGGEPSE

SGSSGSSESGSSEGGPGSSESGSSEGGPGESPGGSSGSESGSGGEPSESGSSGSEGSS

GPGESSGESPGGSSGSESGSEGSSGPGSSESGSSEGGPGSGGEPSESGSSGSEGSSGP

GESSGSEGSSGPGESSGSEGSSGPGESSGSGGEPSESGSSGSGGEPSESGSSGESPGG

SSGSESGESPGGSSGSESGSGGEPSESGSSGSEGSSGPGESSGESPGGSSGSESGSSE

SGSSEGGPGSSESGSSEGGPGSSESGSSEGGPGSGGEPSESGSSGSSESGSSEGGPGE

SPGGSSGSESGSGGEPSESGSSGSSESGSSEGGPGESPGGSSGSESGSGGEPSESGSS

GESPGGSSGSESGSGGEPSESGSS

AE864 25 GSPAGSPTSTEEGTSESATPESGPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGS

APGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPT

STEEGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPS

EGSAPGTSTEPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSEPA

TSGSETPGTSTEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGSP

AGSPTSTEEGTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAPG

TSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSA

PGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGTSESATPE

SGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSPAGSP

TSTEEGSPAGSPTSTEEGSPAGSPTSTEEGTSESATPESGPGTSTEPSEGSAPGTSES

ATPESGPGSEPATSGSETPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGTS

TEPSEGSAPGSPAGSPTSTEEGTSESATPESGPGSEPATSGSETPGTSESATPESGPG

SPAGSPTSTEEGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGTSESATPESG

PGTSESATPESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSTEPSEG

SAPGTSTEPSEGSAPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAP

AF864 26 GSTSESPSGTAPGTSPSGESSTAPGSTSESPSGTAPGSTSESPSGTAPGTSTPESGSAS

PGTSTPESGSASPGSTSESPSGTAPGSTSESPSGTAPGTSPSGESSTAPGSTSESPSGT

APGTSPSGESSTAPGTSPSGESSTAPGSTSSTAESPGPGTSPSGESSTAPGTSPSGESS

TAPGSTSSTAESPGPGTSTPESGSASPGTSTPESGSASPGSTSESPSGTAPGSTSESPS

GTAPGTSTPESGSASPGSTSSTAESPGPGTSTPESGSASPGSTSESPSGTAPGTSPSG

ESSTAPGSTSSTAESPGPGTSPSGESSTAPGTSTPESGSASPGSTSSTAESPGPGSTSS

TAESPGPGSTSSTAESPGPGSTSSTAESPGPGTSPSGESSTAPGSTSESPSGTAPGSTS

ESPSGTAPGTSTPESGPXXXGASASGAPSTXXXXSESPSGTAPGSTSESPSGTAPGS SI.O

I .N

I I) Amino Acid S (|ii nc

Nsi mi- NO:

TSESPSGTAPGSTSESPSGTAPGSTSESPSGTAPGSTSESPSGTAPGTSTPESGSASPG TSPSGESSTAPGTSPSGESSTAPGSTSSTAESPGPGTSPSGESSTAPGTSTPESGSASP GSTSESPSGTAPGSTSESPSGTAPGTSPSGESSTAPGSTSESPSGTAPGTSTPESGSAS PGTSTPESGSASPGSTSESPSGTAPGTSTPESGSASPGSTSSTAESPGPGSTSESPSGT APGSTSESPSGTAPGTSPSGESSTAPGSTSSTAESPGPGTSPSGESSTAPGTSTPESGS ASPGTSPSGESSTAPGTSPSGESSTAPGTSPSGESSTAPGSTSSTAESPGPGSTSSTAE SPGPGTSPSGESSTAPGSSPSASTGTGPGSSTPSGATGSPGSSTPSGATGSP

AG864 27 GASPGTSSTGSPGSSPSASTGTGPGSSPSASTGTGPGTPGSGTASSSPGSSTPSGATG

SPGSSPSASTGTGPGASPGTSSTGSPGTPGSGTASSSPGSSTPSGATGSPGTPGSGTA

SSSPGASPGTSSTGSPGASPGTSSTGSPGTPGSGTASSSPGSSTPSGATGSPGASPGT

SSTGSPGTPGSGTASSSPGSSTPSGATGSPGSSPSASTGTGPGSSPSASTGTGPGSST

PSGATGSPGSSTPSGATGSPGASPGTSSTGSPGASPGTSSTGSPGASPGTSSTGSPGT

PGSGTASSSPGASPGTSSTGSPGASPGTSSTGSPGASPGTSSTGSPGSSPSASTGTGP

GTPGSGTASSSPGASPGTSSTGSPGASPGTSSTGSPGASPGTSSTGSPGSSTPSGATG

SPGSSTPSGATGSPGASPGTSSTGSPGTPGSGTASSSPGSSTPSGATGSPGSSTPSGA

TGSPGSSTPSGATGSPGSSPSASTGTGPGASPGTSSTGSPGASPGTSSTGSPGTPGSG

TASSSPGASPGTSSTGSPGASPGTSSTGSPGASPGTSSTGSPGASPGTSSTGSPGTPG

SGTASSSPGSSTPSGATGSPGTPGSGTASSSPGSSTPSGATGSPGTPGSGTASSSPGS

STPSGATGSPGSSTPSGATGSPGSSPSASTGTGPGSSPSASTGTGPGASPGTSSTGSP

GTPGSGTASSSPGSSTPSGATGSPGSSPSASTGTGPGSSPSASTGTGPGASPGTSSTG

SPGASPGTSSTGSPGSSTPSGATGSPGSSPSASTGTGPGASPGTSSTGSPGSSPSAST

GTGPGTPGSGTASSSPGSSTPSGATGSPGSSTPSGATGSPGASPGTSSTGSP

AM87 28 GTSTEPSEGSAPGSEPATSGSETPGSPAGSPTSTEEGSTSSTAESPGPGTSTPESGSA 5 SPGSTSESPSGTAPGSTSESPSGTAPGTSTPESGSASPGTSTPESGSASPGSEPATSGS

ETPGTSESATPESGPGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGTSTEPSE

GSAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEPSEGSAPGTSESA

TPESGPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTST

EPSEGSAPGSEPATSGSETPGSPAGSPTSTEEGSSTPSGATGSPGTPGSGTASSSPGS

STPSGATGSPGTSTEPSEGSAPGTSTEPSEGSAPGSEPATSGSETPGSPAGSPTSTEE

GSPAGSPTSTEEGTSTEPSEGSAPGASASGAPSTGGTSESATPESGPGSPAGSPTSTE

EGSPAGSPTSTEEGSTSSTAESPGPGSTSESPSGTAPGTSPSGESSTAPGTPGSGTAS

SSPGSSTPSGATGSPGSSPSASTGTGPGSEPATSGSETPGTSESATPESGPGSEPATS

GSETPGSTSSTAESPGPGSTSSTAESPGPGTSPSGESSTAPGSEPATSGSETPGSEPA

TSGSETPGTSTEPSEGSAPGSTSSTAESPGPGTSTPESGSASPGSTSESPSGTAPGTST

EPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGSSTPSGATGSPGSSPSASTGTGPGA

SPGTSSTGSPGSEPATSGSETPGTSESATPESGPGSPAGSPTSTEEGSSTPSGATGSP

GSSPSASTGTGPGASPGTSSTGSPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGS

AP

AE912 29 MAEPAGSPTSTEEGTPGSGTASSSPGSSTPSGATGSPGASPGTSSTGSPGSPAGSPT

STEEGTSESATPESGPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEPS

EGSAPGTSESATPESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSES

ATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTS

TEPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPG

TSTEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGSPAGSPTSTE

EGTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEG

SAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSP

TSTEEGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGSEPA

TSGSETPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSPAGSPTSTEEGSP

AGSPTSTEEGSPAGSPTSTEEGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPG

SEPATSGSETPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSA

PGSPAGSPTSTEEGTSESATPESGPGSEPATSGSETPGTSESATPESGPGSPAGSPTS

TEEGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGTSESAT

PESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSTEPSEGSAPGTSTE

PSEGSAPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAP

AM92 30 MAEPAGSPTSTEEGASPGTSSTGSPGSSTPSGATGSPGSSTPSGATGSPGTSTEPSE 3 GSAPGSEPATSGSETPGSPAGSPTSTEEGSTSSTAESPGPGTSTPESGSASPGSTSESP

SGTAPGSTSESPSGTAPGTSTPESGSASPGTSTPESGSASPGSEPATSGSETPGTSES SI.O

I .N

I I) Amino Acid Νι-ψιι-ιιΐΐ

Nsi mi- NO:

ATPESGPGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTS

TEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEPSEGSAPGTSESATPESGPG

TSESATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSTEPSEGSA

PGSEPATSGSETPGSPAGSPTSTEEGSSTPSGATGSPGTPGSGTASSSPGSSTPSGAT

GSPGTSTEPSEGSAPGTSTEPSEGSAPGSEPATSGSETPGSPAGSPTSTEEGSPAGSP

TSTEEGTSTEPSEGSAPGASASGAPSTGGTSESATPESGPGSPAGSPTSTEEGSPAGS

PTSTEEGSTSSTAESPGPGSTSESPSGTAPGTSPSGESSTAPGTPGSGTASSSPGSSTP

SGATGSPGSSPSASTGTGPGSEPATSGSETPGTSESATPESGPGSEPATSGSETPGST

SSTAESPGPGSTSSTAESPGPGTSPSGESSTAPGSEPATSGSETPGSEPATSGSETPG

TSTEPSEGSAPGSTSSTAESPGPGTSTPESGSASPGSTSESPSGTAPGTSTEPSEGSAP

GTSTEPSEGSAPGTSTEPSEGSAPGSSTPSGATGSPGSSPSASTGTGPGASPGTSSTG

SPGSEPATSGSETPGTSESATPESGPGSPAGSPTSTEEGSSTPSGATGSPGSSPSAST

GTGPGASPGTSSTGSPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGSAP

AM13 31 GTSTEPSEGSAPGSEPATSGSETPGSPAGSPTSTEEGSTSSTAESPGPGTSTPESGSA 18 SPGSTSESPSGTAPGSTSESPSGTAPGTSTPESGSASPGTSTPESGSASPGSEPATSGS

ETPGTSESATPESGPGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGTSTEPSE

GSAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEPSEGSAPGTSESA

TPESGPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTST

EPSEGSAPGSEPATSGSETPGSPAGSPTSTEEGSSTPSGATGSPGTPGSGTASSSPGS

STPSGATGSPGTSTEPSEGSAPGTSTEPSEGSAPGSEPATSGSETPGSPAGSPTSTEE

GSPAGSPTSTEEGTSTEPSEGSAPGPEPTGPAPSGGSEPATSGSETPGTSESATPESG

PGSPAGSPTSTEEGTSESATPESGPGSPAGSPTSTEEGSPAGSPTSTEEGTSESATPE

SGPGSPAGSPTSTEEGSPAGSPTSTEEGSTSSTAESPGPGSTSESPSGTAPGTSPSGES

STAPGSTSESPSGTAPGSTSESPSGTAPGTSPSGESSTAPGTSTEPSEGSAPGTSESA

TPESGPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSESATPESGPGTST

EPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSPSGESSTAPGTSPSGESSTAPGT

SPSGESSTAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGSSPSASTGTGP

GSSTPSGATGSPGSSTPSGATGSPGSSTPSGATGSPGSSTPSGATGSPGASPGTSSTG

SPGASASGAPSTGGTSPSGESSTAPGSTSSTAESPGPGTSPSGESSTAPGTSESATPE

SGPGTSTEPSEGSAPGTSTEPSEGSAPGSSPSASTGTGPGSSTPSGATGSPGASPGTS

STGSPGTSTPESGSASPGTSPSGESSTAPGTSPSGESSTAPGTSESATPESGPGSEPAT

SGSETPGTSTEPSEGSAPGSTSESPSGTAPGSTSESPSGTAPGTSTPESGSASPGSPA

GSPTSTEEGTSESATPESGPGTSTEPSEGSAPGSPAGSPTSTEEGTSESATPESGPGS

EPATSGSETPGSSTPSGATGSPGASPGTSSTGSPGSSTPSGATGSPGSTSESPSGTAP

GTSPSGESSTAPGSTSSTAESPGPGSSTPSGATGSPGASPGTSSTGSPGTPGSGTASS

SPGSPAGSPTSTEEGSPAGSPTSTEEGTSTEPSEGSAP

BC 32 GTSTEPSEPGSAGTSTEPSEPGSAGSEPATSGTEPSGSGASEPTSTEPGSEPATSGTE 864 PSGSEPATSGTEPSGSEPATSGTEPSGSGASEPTSTEPGTSTEPSEPGSAGSEPATSG

TEPSGTSTEPSEPGSAGSEPATSGTEPSGSEPATSGTEPSGTSTEPSEPGSAGTSTEPS

EPGSAGSEPATSGTEPSGSEPATSGTEPSGTSEPSTSEPGAGSGASEPTSTEPGTSEP

STSEPGAGSEPATSGTEPSGSEPATSGTEPSGTSTEPSEPGSAGTSTEPSEPGSAGSG

ASEPTSTEPGSEPATSGTEPSGSEPATSGTEPSGSEPATSGTEPSGSEPATSGTEPSG

TSTEPSEPGSAGSEPATSGTEPSGSGASEPTSTEPGTSTEPSEPGSAGSEPATSGTEP

SGSGASEPTSTEPGTSTEPSEPGSAGSGASEPTSTEPGSEPATSGTEPSGSGASEPTS

TEPGSEPATSGTEPSGSGASEPTSTEPGTSTEPSEPGSAGSEPATSGTEPSGSGASEP

TSTEPGTSTEPSEPGSAGSEPATSGTEPSGTSTEPSEPGSAGSEPATSGTEPSGTSTEP

SEPGSAGTSTEPSEPGSAGTSTEPSEPGSAGTSTEPSEPGSAGTSTEPSEPGSAGTST

EPSEPGSAGTSEPSTSEPGAGSGASEPTSTEPGTSTEPSEPGSAGTSTEPSEPGSAGT

STEPSEPGSAGSEPATSGTEPSGSGASEPTSTEPGSEPATSGTEPSGSEPATSGTEPS

GSEPATSGTEPSGSEPATSGTEPSGTSEPSTSEPGAGSEPATSGTEPSGSGASEPTST

EPGTSTEPSEPGSAGSEPATSGTEPSGSGASEPTSTEPGTSTEPSEPGSA

BD864 33 GSETATSGSETAGTSESATSESGAGSTAGSETSTEAGTSESATSESGAGSETATSGS

ETAGSETATSGSETAGTSTEASEGSASGTSTEASEGSASGTSESATSESGAGSETAT SGSETAGTSTEASEGSASGSTAGSETSTEAGTSESATSESGAGTSESATSESGAGSE TATSGSETAGTSESATSESGAGTSTEASEGSASGSETATSGSETAGSETATSGSETA GTSTEASEGSASGSTAGSETSTEAGTSESATSESGAGTSTEASEGSASGSETATSGS ETAGSTAGSETSTEAGSTAGSETSTEAGSETATSGSETAGTSESATSESGAGTSESA SI.O

I .N

I I) Amino Acid Νι-ψιι-ιιΐΐ

Niiim- NO:

TSESGAGSETATSGSETAGTSESATSESGAGTSESATSESGAGSETATSGSETAGSE

TATSGSETAGTSTEASEGSASGSTAGSETSTEAGSETATSGSETAGTSESATSESGA

GSTAGSETSTEAGSTAGSETSTEAGSTAGSETSTEAGTSTEASEGSASGSTAGSETS

TEAGSTAGSETSTEAGTSTEASEGSASGSTAGSETSTEAGSETATSGSETAGTSTEA

SEGSASGTSESATSESGAGSETATSGSETAGTSESATSESGAGTSESATSESGAGSE

TATSGSETAGTSESATSESGAGSETATSGSETAGTSTEASEGSASGTSTEASEGSAS

GSTAGSETSTEAGSTAGSETSTEAGSETATSGSETAGTSESATSESGAGTSESATSE

SGAGSETATSGSETAGSETATSGSETAGSETATSGSETAGTSTEASEGSASGTSESA

TSESGAGSETATSGSETAGSETATSGSETAGTSESATSESGAGTSESATSESGAGSE

TATSGSETA

AE911 34 AEPAGSPTSTEEGTPGSGTASSSPGSSTPSGATGSPGASPGTSSTGSPGSPAGSPTST

EEGTSESATPESGPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEPSE

GSAPGTSESATPESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSESA

TPESGPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTST

EPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGT

STEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGSPAGSPTSTEE

GTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGS

APGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPT

STEEGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGSEPAT

SGSETPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSPAGSPTSTEEGSPA

GSPTSTEEGSPAGSPTSTEEGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGS

EPATSGSETPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAP

GSPAGSPTSTEEGTSESATPESGPGSEPATSGSETPGTSESATPESGPGSPAGSPTST

EEGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGTSESATP

ESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEP

SEGSAPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAP

AE146 35 GGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSTEPSEG

SAPGTSTEPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPS EGSAPGSPAGSPTSTEEGTSTEPSEGSAPG

AE48. 36 AEPAGSPTSTEEGTPGSGTASSSPGSSTPSGATGSPGASPGTSSTGS

1

AM48. 37 AEPAGSPTSTEEGASPGTSSTGSPGSSTPSGATGSPGSSTPSGATGS

1

AE912 38 AEPAGSPTSTEEGTPGSGTASSSPGSSTPSGATGSPGASPGTSSTGSPGSPAGSPTST .1 EEGTSESATPESGPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEPSE

GSAPGTSESATPESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSESA

TPESGPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTST

EPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGT

STEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGSPAGSPTSTEE

GTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGS

APGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPT

STEEGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGSEPAT

SGSETPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSPAGSPTSTEEGSPA

GSPTSTEEGSPAGSPTSTEEGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGS

EPATSGSETPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAP

GSPAGSPTSTEEGTSESATPESGPGSEPATSGSETPGTSESATPESGPGSPAGSPTST

EEGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGTSESATP

ESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEP

SEGSAPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAP

AE912 39 AEPAGSPTSTEEGTPGSGTASSSPGSSTPSGATGSPGASPGTSSTGSPGSPAGSPTST .2 EEGTSESATPESGPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEPSE

GSAPGTSESATPESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSESA

TPESGPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPTSTEEGTSTEPSEGSAPGTST

EPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGT

STEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGSPAGSPTSTEE

GTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGS

APGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEGSAPGSPAGSPT SI.O

XTEN I I) Amino Acid Νι-ψιι-ιιΐΐ

Nsi mi- NO:

STEEGTSTEPSEGSAPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGSEPAT SGSETPGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGSPAGSPTSTEEGSPA GSPTSTEEGSPAGSPTSTEEGTSESATPESGPGTSTEPSEGSAPGTSESATPESGPGS EPATSGSETPGTSESATPESGPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAP GSPAGSPTSTEEGTSESATPESGPGSEPATSGSETPGTSESATPESGPGSPAGSPTST EEGSPAGSPTSTEEGTSTEPSEGSAPGTSESATPESGPGTSESATPESGPGTSESATP ESGPGSEPATSGSETPGSEPATSGSETPGSPAGSPTSTEEGTSTEPSEGSAPGTSTEP SEGSAPGSEPATSGSETPGTSESATPESGPGTSTEPSEGSAPG

AE146 40 TSESATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGTSESATPESGPGTSTEPSEGSA .1 PGTSTEPSEGSAPGTSESATPESGPGTSTEPSEGSAPGTSTEPSEGSAPGTSTEPSEG

SAPGSPAGSPTSTEEGTSTEPSEGSAPG

In those embodiments wherein the XTEN component of the hGH-XTEN fusion protein has less than 100% of its amino acids consisting of 4, 5, or 6 types of amino acid selected from glycine (G), alanine (A), serine (S), threonine (T), glutamate (E) and proline (P), or less than 100% of the sequence consisting of the XTEN sequences of Table 2, the other amino acid residues of the XTEN are selected from any of the other 14 natural L-amino acids, but are preferentially selected from hydrophilic amino acids such that the XTEN sequence contains at least about 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or at least about 99% hydrophilic amino acids. The XTEN amino acids that are not glycine (G), alanine (A), serine (S), threonine (T), glutamate (E) and proline (P) are either interspersed throughout the XTEN sequence, are located within or between the sequence motifs, or are concentrated in one or more short stretches of the XTEN sequence, e.g., to create a linker between the XTEN and the hGH components. In such cases where the XTEN component of the hGH-XTEN comprises amino acids other than glycine (G), alanine (A), serine (S), threonine (T), glutamate (E) and proline (P), it is preferred that less than about 2% or less than about 1% of the amino acids be hydrophobic residues such that the resulting sequences generally lack secondary structure, e.g., not having more than 2% alpha helices or 2% beta- sheets, as determined by the methods disclosed herein. Hydrophobic residues that are less favored in construction of XTEN include tryptophan, phenylalanine, tyrosine, leucine, isoleucine, valine, and methionine. Additionally, one can design the XTEN sequences to contain less than 5% or less than 4% or less than 3% or less than 2% or less than 1% or none of the following amino acids: cysteine (to avoid disulfide formation and oxidation), methionine (to avoid oxidation), asparagine and glutamine (to avoid desamidation). Thus, in some embodiments, the XTEN component of the hGH-XTEN fusion protein comprising other amino acids in addition to glycine (G), alanine (A), serine (S), threonine (T), glutamate (E) and proline (P) have a sequence with less than 5% of the residues contributing to alpha- helices and beta-sheets as measured by the Chou-Fasman algorithm and have at least 90%, or at least about 95% or more random coil formation as measured by the GOR algorithm.

4. XTEN segments

In one embodiment, the present disclosure provides an isolated hGH-XTEN fusion protein wherein the cumulative length of the XTEN component is greater than about 100 to about 3000 amino acid residues containing at least one polypeptide sequence segment selected from Table 2 (and Tables 8, 9, 10, 11, and 12 of Schellenberger et al.

WO10/144502A2, which is incorporated herein by reference in its entirety) and wherein at least about 90%, or at least about 91%, or at least about 92%, or at least about 93%, or at least about 94%), or at least about 95%, or at least about 96%, or at least about 97%, or at least about 98%) or more of the remainder of the XTEN sequence by and large contains hydrophilic amino acids and less than about 2% of the remainder of the XTEN consists of hydrophobic or aromatic amino acids, or cysteine. In some embodiments, the XTEN contains multiple segments wherein the segments are identical or different (see Schellenberger et al.

WO10/144502A2; Cleland et al. U.S. 13/829,369; and Cleland et al. W013/184216, each of which is incorporated herein by reference in its entirety).

5. N-terminal XTEN expression-enhancing sequences

In some embodiments, the present disclosure provides a short-length XTEN sequence incorporated as the N-terminal portion of the hGH-XTEN fusion protein. The expression of the fusion protein is enhanced in a host cell transformed with a suitable expression vector comprising an optimized N-terminal leader polynucleotide sequence (that encodes the N- terminal XTEN) incorporated into the polynucleotide encoding the binding fusion protein. It has been discovered, as described in Examples 14-17 of Schellenberger et al.

WO10/144502A2 (which is incorporated herein by reference in its entirety), that a host cell transformed with such an expression vector comprising an optimized N-terminal leader sequence (NTS) in the binding fusion protein gene results in greatly-enhanced expression of the fusion protein compared to the expression of a corresponding fusion protein from a polynucleotide not comprising the NTS, and obviates the need for incorporation of a non- XTEN leader sequence used to enhance expression (see Schellenberger et al.

In one embodiment, the N-terminal XTEN polypeptide of the hGH-XTEN comprises a sequence that exhibits at least about 80%, more preferably at least about 90%, more preferably at least about 91%, more preferably at least about 92%, more preferably at least about 93%), more preferably at least about 94%, more preferably at least about 95%, more preferably at least about 96%, more preferably at least about 97%, more preferably at least about 98%), more preferably at least 99%, or exhibits 100% sequence identity to the amino acid sequence of AE48, AE48.1, AM48, or AM48.1, the respective amino acid sequences of which are as follows:

AE48: MAEPAGSPTSTEEGTPGSGTASSSPGSSTPSGATGSPGASPGTSSTGS (SEQ ID NO: 13) AE48.1 : AEPAGSPTSTEEGTPGSGTASSSPGSSTPSGATGSPGASPGTSSTGS (SEQ ID NO:36) AM48: MAEPAGSPTSTEEGASPGTSSTGSPGSSTPSGATGSPGSSTPSGATGS (SEQ ID NO: 14) AM48.1 : AEPAGSPTSTEEGASPGTSSTGSPGSSTPSGATGSPGSSTPSGATGS (SEQ ID NO:37).

In another embodiment, the N-terminal XTEN polypeptide of the hGH-XTEN comprises a sequence exhibiting at least 90% identity to AE48, AM48 or AE912, as described herein, wherein the N-terminal M residue is absent (e.g., AE48.1 - SEQ ID NO:36; AM48.1 - SEQ ID NO:37; and AE912.1 - SEQ ID NO:38). In an additional embodiment, the C-terminal XTEN polypeptide of the hGH-XTEN comprises a sequence exhibiting at least 90% identity to AE146, as described herein, (e.g., AE146 - SEQ ID NO:35; or AE146.1 - SEQ ID NO:40).

In another embodiment, the short-length N-terminal XTEN is linked to an XTEN of longer length to form the N-terminal region of the hGH-XTEN fusion protein, wherein the polynucleotide sequence encoding the short-length N-terminal XTEN confers the property of enhanced expression in the host cell, and wherein the long length of the expressed XTEN contributes to the enhanced properties of the XTEN carrier in the fusion protein, as described above. In some embodiments, the N-terminal XTEN polypeptide with long length exhibits at least about 80%, or at least about 90%, or at least about 91%, or at least about 92%, or at least about 93%), or at least about 94%, or at least about 95%, or at least about 96%, or at least about 97%), or at least about 98%, or at least 99%, or exhibits 100% sequence identity to an amino acid sequence selected from the group consisting of the sequences AE624, AE91 1, AE912, and AM923.

6. Net charge

In other embodiments, the XTEN polypeptides have an unstructured characteristic imparted by incorporation of amino acid residues with a net charge and/or reducing the proportion of hydrophobic amino acids in the XTEN sequence. The overall net charge and net charge density is controlled by modifying the content of charged amino acids in the XTEN sequences. In some embodiments, the net charge density of the XTEN of the compositions may be above +0.1 or below -0.1 charges/residue. In other embodiments, the net charge of a XTEN can be about 0%, about 1%, about 2%, about 3%, about 4%, about 5%, about 6%, about 7%, about 8%, about 9%, about 10% about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, or about 20% or more (see Schellenberger et al. WO10/144502A2; Cleland et al. U.S. 13/829,369; and Cleland et al. PCT/US2013/031673, each of which is incorporated herein by reference in its entirety).

7. Low immunogenicity

In another aspect, the present disclosure provides compositions in which the XTEN sequences have a low degree of immunogenicity or are substantially non-immunogenic.

Several factors can contribute to the low immunogenicity of XTEN, e.g., the non-repetitive sequence, the unstructured conformation, the high degree of solubility, the low degree or lack of self-aggregation, the low degree or lack of proteolytic sites within the sequence, and the low degree or lack of epitopes in the XTEN sequence (see Schellenberger et al.

WO10/144502A2; Cleland et al. U.S. 13/829,369; and Cleland et al. PCT/US2013/031673, each of which is incorporated herein by reference in its entirety).

8. Increased hydrodynamic radius

In another aspect, the present disclosure provides XTEN in which the XTEN polypeptides have a high hydrodynamic radius that confers a corresponding increased Apparent Molecular Weight to the hGH-XTEN fusion protein incorporating the XTEN. As detailed in Example 37 of Schellenberger et al. WO10/144502A2, the linking of XTEN to GH sequences results in hGH-XTEN compositions that can have increased hydrodynamic radii, increased Apparent Molecular Weight, and increased Apparent Molecular Weight Factor compared to a GH not linked to an XTEN (see Schellenberger et al. WO10/144502A2; Cleland et al. U.S. 13/829,369; and Cleland et al. W013/184216, each of which is

incorporated herein by reference in its entirety).

V). hGH-XTEN STRUCTURAL CONFIGURATIONS AND PROPERTIES

The human growth hormone (GH) of the subject compositions are not limited to native, full-length polypeptides, but also include recombinant versions as well as biologically and/or pharmacologically active variants or fragments thereof. For example, it will be appreciated that various amino acid deletions, insertions and substitutions can be made in the GH to create variants without departing from the spirit of the invention with respect to the biological activity or pharmacologic properties of the GH. Examples of conservative substitutions for amino acids in polypeptide sequences are shown in Table 3. However, in embodiments of the hGH-XTEN in which the sequence identity of the GH is less than 100% compared to a specific sequence disclosed herein, the invention contemplates substitution of any of the other 19 natural L-amino acids for a given amino acid residue of the given GH, which may be at any position within the sequence of the GH, including adjacent amino acid residues. If any one substitution results in an undesirable change in biological activity, then one of the alternative amino acids can be employed and the construct evaluated by the methods described herein, or using any of the techniques and guidelines for conservative and non-conservative mutations set forth, for instance, in U.S. Pat. No. 5,364,934, the content of which is incorporated by reference in its entirety, or using methods generally known in the art. In addition, variants can include, for instance, polypeptides wherein one or more amino acid residues are added or deleted at the N- or C-terminus of the full-length native amino acid sequence of a GH that retains some if not all of the biological activity of the native peptide.

(a) Fusion Protein Configurations

In some embodiments, the present disclosure provides fusion protein compositions with the GH and XTEN components linked in specific N- to C-terminus configurations. In some

embodiments, one or more GHs are linked to one or more XTENs, either at the N-terminus or at the C-terminus, with or without a spacer, to form a block copolymer, and the sequential arrangement of the GHs and the XTENs in the fusion protein are the same as the configuration known in the block copolymer chemistry. When there is more than one GH, XTEN, or spacer, each of the GH, the XTEN, or the spacer have the same or different sequences, and the GHs and/or XTENs are linked either continuously or alternately (regular or irregular). Thus, in all of the formulae provided herein, when there is more than one GH, XTEN, or spacer, each of the GH, XTEN, and spacer are the same or different. In some embodiments, the fusion protein is a monomeric fusion protein with a GH linked to one XTEN polypeptide. In other embodiments, the fusion protein is a monomeric fusion protein with a GH linked to two or more XTEN polypeptides. In still other embodiments, the fusion protein is a monomeric fusion protein with two or more GH linked to one XTEN polypeptide. In still other embodiments, the fusion protein is a monomeric fusion protein with two or more GH linked to two or more XTEN polypeptide. Table 4 provides non-limiting examples of configurations that are encompassed by the invention; numerous other variations will be apparent to the ordinarily skilled artisan, including the incorporation of the spacer and cleavage sequences disclosed herein or known in the art.

Table 4: hGH-XTEN configurations

* Characterized as single for 1 component or multiple for 2 or more of that component

** Reflects N- to C-terminus configuration of the growth factor and XTEN components

In some embodiments, are provided fusion proteins compositions that are in a configuration shown in Table 4 and that retain at least a portion of the biological activity of the corresponding GH not linked to the XTEN. In other embodiments, the GH component either becomes biologically active or has an increase in activity upon its release from the XTEN by cleavage of an optional cleavage sequence incorporated within spacer sequences into the hGH-XTEN, described more fully below.

In one embodiment of the hGH-XTEN composition, is provided a fusion protein of formula I:

(XTEN)x-GH-(XTEN)y I

wherein independently for each occurrence, GH is a human growth hormone; x is either 0 or 1 and y is either 0 or 1 wherein x+y >1; and XTEN is an extended recombinant polypeptide.

In another embodiment of the hGH-XTEN composition, is provided a fusion protein of formula II:

(XTEN)x-(GH)-(S)y-(XTEN) y II

wherein independently for each occurrence, GH is a human growth hormone; S is a spacer sequence having between 1 to about 50 amino acid residues that can optionally include a cleavage sequence; x is either 0 or 1 and y is either 0 or 1 wherein x+y >1; and XTEN is an extended recombinant polypeptide.

In another embodiment, is provided an isolated fusion protein, wherein the fusion protein is of formula III:

(GH)-(S)x-(XTEN)-(S)y-(GH)-(S)z-(XTEN)z III

wherein independently for each occurrence, GH is a human growth hormone; S is a spacer sequence having between 1 to about 50 amino acid residues that can optionally include a cleavage sequence; x is either 0 or 1; y is either 0 or 1; z is either 0 or 1; and XTEN is an extended recombinant polypeptide.

In another embodiment, is provided an isolated fusion protein, wherein the fusion protein is of formula IV:

(XTEN)x-(S)y-(GH)-(S)z-(XTEN)-(GH) IV

In another embodiment, is provided an isolated fusion protein, wherein the fusion protein is of formula V:

(GH)x-(S)x-(GH)-(S)y-(XTEN) V

wherein independently for each occurrence, GH is a growth hormone; S is a spacer sequence having between 1 to about 50 amino acid residues that can optionally include a cleavage sequence; x is either 0 or 1; y is either 0 or 1; and XTEN is an extended recombinant polypeptide.

In another embodiment, is provided an isolated fusion protein, wherein the fusion protein is of formula VI:

(XTEN)-(S)x-(GH)-(S)y-(GH) VI

In another embodiment, is provided an isolated fusion protein, wherein the fusion protein is of formula VII:

(XTEN)-(S)x-(GH)-(S)y-(GH)-(XTEN) VII

In another embodiment, is provided an isolated fusion protein, wherein the fusion protein is of formula VIII:

((S)m-(GH)x-(S)n-(XTEN)y-(S)o)t VIII wherein t is an integer that is greater than 0 (1, 2, 3, etc.); independently each of m, n, o, x , and y is an integer (0, 1, 2, 3, etc.), GH is a growth hormone; S is an spacer, optionally comprising a cleavage site; and XTEN is an extended recombinant polypeptide, with the proviso that: (1) x+ y > 1, (2) when t = 1, x>0 and y>0, (3) when there is more than one GH, S, or XTEN, each GH, XTEN, or S are the same or are independently different; and (4) when t >1, each m, n, o, x, or y within each subunit are the same or are independently different.

In another embodiment, is provided an isolated fusion protein, wherein the fusion protein is of formula IX:

(XTEN)x-(S)x-(GH)-(S)y-(XTEN)y IX

Any spacer sequence group is optional in the fusion proteins encompassed by the invention. The spacer is provided to enhance expression of the fusion protein from a host cell or to decrease steric hindrance such that the GH component may assume its desired tertiary structure and/or interact appropriately with its target receptor. For spacers and methods of identifying desirable spacers, see, for example, George, et al. (2003) Protein Engineering 15:871-879, specifically incorporated by reference herein. In one embodiment, the spacer comprises one or more peptide sequences that are between 1-50 amino acid residues in length, or about 1-25 residues, or about 1-10 residues in length. Spacer sequences, exclusive of cleavage sites, can comprise any of the 20 natural L amino acids, and will preferably comprise hydrophilic amino acids that are sterically unhindered that can include, but not be limited to, glycine (G), alanine (A), serine (S), threonine (T), glutamate (E) and proline (P). In some cases, the spacer can be polyglycines or polyalanines, or is predominately a mixture of combinations of glycine and alanine residues. The spacer polypeptide exclusive of a cleavage sequence is largely to substantially devoid of secondary structure; e.g., less than about 10%, or less than about 5% as determined by the Chou-Fasman and/or GOR

algorithms. In one embodiment, one or both spacer sequences in a hGH-XTEN fusion protein composition each further contains a cleavage sequence, which are identical or different, wherein the cleavage sequence may be acted on by a protease to release the GH from the fusion protein.

In one embodiment, a GH incorporated into a hGH-XTEN fusion protein has a sequence that exhibits at least about 80% sequence identity to a sequence shown as SEQ ID NO:41, alternatively at least about 81%, or about 82%, or about 83%>, or about 84%>, or about 85%, or about 86%, or about 87%, or about 88%, or about 89%, or about 90%, or about 91%, or about 92%, or about 93%, or about 94%, or about 95%, or about 96%, or about 97%, or about 98%), or about 99%, or about 100%> sequence identity as compared with the sequence of SEQ ID NO:41. The GH of the foregoing embodiment can be evaluated for activity using assays or measured or determined parameters as described herein, and those sequences that retain at least about 40%, or about 50%, or about 55%, or about 60%, or about 70%, or about 80%), or about 90%, or about 95% or more activity compared to the corresponding native GH sequence would be considered suitable for inclusion in the subject hGH-XTEN. The GH found to retain a suitable level of activity can be linked to one or more XTEN polypeptides described hereinabove. In one embodiment, a GH found to retain a suitable level of activity can be linked to one or more XTEN polypeptides having at least about 80% sequence identity to a sequence from Table 3, alternatively at least about 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or about 100% sequence identity as compared with a sequence of Table 3, resulting in a chimeric fusion protein.

Non-limiting examples of sequences of fusion proteins containing a single GH linked to a single XTEN are presented in Table 35 of Schellenberger et al. WO10/144502A2, which is incorporated herein by reference in its entirety. In one embodiment, a hGH-XTEN composition would comprise a fusion protein having at least about 80% sequence identity to a hGH-XTEN from Table 35 of Schellenberger et al. WO10/144502A2 (which is

incorporated herein by reference in its entirety), alternatively at least about 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or about 100% sequence identity as compared with a hGH-XTEN from Table 35 of

Schellenberger et al. WO10/144502A2, which is incorporated herein by reference in its entirety. Non-limiting examples of sequences of fusion proteins containing two molecules of XTEN linked to one or more GH are presented in Table 36 of Schellenberger et al.

WO10/144502A2 (which is incorporated herein by reference in its entirety), but the invention also contemplates substitution of other GH with sequences exhibiting at least about 90% sequence identity to the sequence of SEQ ID NO:41 linked to one or two XTEN, which may be the same or different, exhibiting at least about 90% sequence identity to sequences selected from Table 2. Non-limiting examples of hGH-XTEN comprising GH, XTEN, and spacer amino acids are presented in Table 37 of Schellenberger et al. WO10/144502A2, which is incorporated herein by reference in its entirety, (see also Schellenberger et al. WO10/144502A2; Cleland et al. U.S. 13/829,369; and Cleland et al. W013/184216, each of which is incorporated herein by reference in its entirety).

VI). USES OF THE COMPOSITIONS OF THE PRESENT INVENTION

Most processes involved in growth of the body are regulated by multiple peptides and hormones, and such peptides and hormones, as well as analogues thereof, have found utility in the treatment of growth hormone-related diseases, disorders and conditions. However, the use of commercially-available growth hormones to treat pediatric patients, has met with less than optimal success in the management of pediatric patients afflicted with such diseases, disorders and conditions. In particular, dose optimization and frequency of dosing is important for peptide and hormone biologies used in the treatment of growth hormone-related diseases and disorders in pediatric patients. The fact that growth hormone has a short half- life (e.g., usually less than 4 hours when administered subcutaneously), necessitates frequent (e.g., daily) dosing in order to achieve clinical benefit, which results in difficulties in the management of such pediatric patients. Non-compliance with daily growth hormone (GH) injections can lead to loss of treatment effects.

When compared to the current treatment protocol for recombinant hGH (rhGH), the benefit of an hGH-XTEN fusion protein to pediatric PGHD patients may include a substantial reduction in the number and frequency of injections. For example, in the Phase 2a stage of the clinical trial (see Example 2), pediatric PGHD patients will receive significantly fewer total injections (e.g., 6 total injections, once per month for 6 months) of an hGH-XTEN fusion protein compared to the 180 total injections of rhGH that these patients would have received on daily rhGH therapy over 6 months) than a pediatric patient undergoing daily rhGH therapy would receive over the same time period. The frequency of injection with rhGH in current clinical practice often leads to a lack of compliance. Compliance with daily therapy is crucial in order to realize the full potential for normal growth (Rosenfeld, R. G. & Bakker, B. (2008). Endocr Pract 14, 143-54; Desrosiers, P. et al. (2005). Pediatr Endocrinol Rev 2 Suppl 3, 327-31). An hGH-XTEN fusion protein is expected to provide the advantage of non-daily (e.g., bi-weekly, weekly, every two weeks, every three weeks, or monthly) administration to children with PGHD, and to offer a safe alternative to the current daily injections. An hGH product administered less frequently than daily rhGH therapy may provide greater compliance and therefore better long-term treatment outcomes for PGHD children.

In one aspect, the present disclosure provides a method for achieving a beneficial effect in a disease, disorder or condition mediated by GH including, but not limited to growth hormone deficiency in a pediatric human patient. In another aspect, the invention provides a method for achieving a beneficial effect in a disease, disorder or condition mediated by GH including, but not limited to growth hormone deficiency in pediatric patients. The beneficial effect includes, without limitation, treating, mediating, or ameliorating a GH-related disease, deficiency, disorder or condition. The present disclosure addresses disadvantages and/or limitations of GH that have a relatively short terminal half-life and/or a narrow therapeutic window.

1. Pediatric Growth Hormone Deficiency (PGHD)

"Pediatric Growth Hormone Deficiency" or "PGHD" as used herein refers to a disease, deficiency, disorder or condition in a human pediatric patient that would benefit from treatment with growth hormone. PGHD includes disorders that are classified based on the source of the GH deficiency (e.g., pituitary PGHD, hypothalamic PGHD, functional PGHD, and idiopathic PGHD). Pituitary or "classic" PGHD is the incapacity of the pituitary to produce growth hormone. "Hypothalamic PGHD" is the failure of the hypothalamus to produce and/or transmit the neuroendocrine messaging hormone, growth hormone releasing hormone (GHRH), which directs a properly functioning pituitary to produce GH; "functional PGHD" is the failure of other hormone and of metabolic functions related to the failure of the pituitary to produce, uptake, and/or utilize GH. PGHD also includes, without limitation, idiopathic short stature, Turner syndrome, Prader Willi syndrome, small for gestational age (SGA), growth failure as a result of a deficiency in the short stature homeob ox-containing gene (SHOX deficiency); and chronic kidney disease (CKD). The PGHD may be congenital or acquired in nature.

PGHD may also occur as a result of intrauterine growth retardation, congenital hypopituitarism or acquired hypopituitarism (including hypopituitarism caused by a tumor, e.g., craniopharyngioma); small for gestational age, developmental defects in or near the pituitary gland; genetic problems with the production of GH; Prader-Willi syndrome; Turner syndrome; idiopathic short stature; intrauterine growth retardation; midline facial defects; and damage to the pituitary gland or the surrounding area due to tumors, infection, radiation treatment, or severe head injury.

PGHD may be classified based on the stage of life the GH deficiency became manifest. For example, an adolescent may have PGHD that is a continuation of childhood onset PGHD (including child-onset PGHD and child-onset idiopathic PGHD), which began in infancy or pre-adolescent childhood. The causes of childhood-onset PGHD are provided above. Adolescents who survived brain tumors as pre-adolescent children may be at risk of developing PGHD from the effects of surgery, cranial radiation or chemotherapy. PGHD can develop in an adolescent, i.e., childhood-onset PGHD, who was not diagnosed as being GH- deficient as a pre-adolescent child. PGHD may be caused by damage or trauma to the pituitary gland. The damage is typically caused by a tumor {e.g., a tumor in and/or around the pituitary gland; or a tumor in the hypothalamus). Pituitary tumors can compress the gland or damage can occur when the tumor is removed via neurosurgery. The pituitary can also be damaged by infection, blood vessel disease, severe head injury, or cranial radiation or chemotherapy for treating tumors of the head and neck. PGHD may be caused by: trauma that occurred in a child or adolescent at their birth or soon after their birth; central nervous system infection; tumors of the hypothalamus or pituitary glands; infiltrative or

granulomatous disease; cranial irradation; surgery; or idiopathic causes.

2. hGH-XTEN Bolus Doses and Dosage Regimens

In one aspect, the present disclosure provides a method of treating pediatric growth hormone deficiency (PGHD) in a human pediatric patient by administering a human growth hormone-XTEN (hGH-XTEN) fusion protein to the patient. In one embodiment, the method comprises administering the hGH-XTEN fusion protein to the pediatric patient as a bolus dose. In another embodiment, the bolus dose is a therapeutically effective bodyweight adjusted bolus dose. In one other embodiment, the bolus dose is between about 0.8 mg/kg and about 6.3 mg/kg. In one embodiment, the fusion protein comprises an amino acid sequence having at least about 90% sequence identity to SEQ ID NO: 1. In another embodiment, the fusion protein comprises an amino acid sequence having at least about 91%, or at least about 92%, or at least about 93%, or at least about 94%, or at least about 95%, or at least about 96%, or at least about 97%, or at least about 98%, or at least about 99% sequence identity to SEQ ID NO: 1. In another embodiment, the fusion protein comprises an amino acid sequence having the sequence of SEQ ID NO: 1.

In one aspect, the bolus dose may be administered over a range of doses. It should be noted that where reference is made to the administration of a bolus dose between about a first mg/kg and about a second mg/kg, the "first mg/kg" term may include the first mg/kg value and the "second mg/kg" term may include the second mg/kg value.

In one embodiment, the hGH-XTEN fusion protein comprises (i) an amino acid sequence having at least about 90% sequence identity to SEQ ID NO: 1; (ii) the amino acid sequence of SEQ ID NO: 1; (iii) an amino acid sequence having at least about 90% sequence identity to SEQ ID NO:4 (AE912-hGH); (iv) the amino acid sequence of SEQ ID NO:4 (AE912-hGH); (v) an amino acid sequence having at least about 90% sequence identity to SEQ ID NO:38; or (vi) the amino acid sequence of SEQ ID NO:38.

In one other aspect, the bolus dose of the hGH-XTEN fusion protein is administered to a human pediatric patient on a regular basis over a suitable time period, which can be finite or indefinite. In one embodiment, the bolus dose is administered every week, every two weeks, every three weeks, or monthly. In other embodiments, the bolus dose is administered once a month, twice a month, three times a month, or four times a month. In another embodiment, the bolus dose is administered about every 7 days, about every 10 days, about every 14 days, about every 21 days, about every 28 days, or about every 30 days. In one embodiment, the bolus dose is administered on a non-daily basis, or is a non-daily bolus dose.

In an additional aspect, the bolus dose of the hGH-XTEN fusion protein is

administered to a human pediatric patient at a dose (i) between about 1.0 mg/kg and about 6.3 mg/kg; (ii) between about 1.0 mg/kg and about 1.5 mg/kg; (iii) between about 2.0 mg/kg and about 3 mg/kg, or (iv) between about 4.5 mg/kg and about 5.5 mg/kg, wherein the dose is administered on a monthly, semimonthly, or weekly basis. In one embodiment, the fusion protein is administered at a dose of about 1.0 mg/kg, about 1.05 mg/kg, about 1.10 mg/kg, about 1.15 mg/kg, about 1.20 mg/kg, about 1.25 mg/kg, about 1.30 mg/kg, about 1.35 mg/kg, about 1.40 mg/kg, about 1.45 mg/kg, and about 1.50 mg/kg, wherein the dose is administered on a monthly, semimonthly, or weekly basis. In another embodiment, the fusion protein is administered at a dose of about 2.0 mg/kg, about 2.10 mg/kg, about 2.20 mg/kg, about 2.30 mg/kg, about 2.40 mg/kg, about 2.50 mg/kg, about 2.60 mg/kg, about 2.70 mg/kg, about 2.80 mg/kg, about 2.90 mg/kg, and about 3.0 mg/kg, wherein the dose is administered on a monthly, semimonthly, or weekly basis. In one other embodiment, the fusion protein is administered at a dose of about 4.50 mg/kg, about 4.60 mg/kg, about 4.70 mg/kg, about 4.80 mg/kg, about 4.90 mg/kg, about 5.0 mg/kg, about 5.10 mg/kg, about 5.20 mg/kg, about 5.30 mg/kg, about 5.40 mg/kg, about 5.50 mg/kg, about 6.0 mg/kg, and about 6.3 mg/kg wherein the dose is administered on a monthly, semimonthly, or weekly basis. In preferred embodiments, the fusion protein is administered (i) at a dose of about 1.15 mg/kg on a weekly basis; (ii) at a dose of about 2.5 mg/kg on a semimonthly basis; and/or (iii) at a dose of about 5.0 mg/kg on a monthly basis.

In another embodiment, the fusion protein is administered at a dose of about 0.8 mg/kg, about 0.9 mg/kg, 1.60 mg/kg, about 1.70 mg/kg, about 1.80 mg/kg, about 1.90 mg/kg, about 3.10 mg/kg, about 3.20 mg/kg, about 3.30 mg/kg, about 3.40 mg/kg, about 3.50 mg/kg, about 3.60 mg/kg, about 3.70 mg/kg, about 3.80 mg/kg, about 3.9 mg/kg, about 4.0 mg/kg, about 4.10 mg/kg, about 4.20 mg/kg, about 4.30 mg/kg, about 4.40 mg/kg, about 5.60 mg/kg, about 5.70 mg/kg, about 5.80 mg/kg, and about 5.90 mg/kg, wherein the dose is administered on a monthly, semimonthly, or weekly basis.

In another aspect, additional bolus doses and ranges of bolus doses of the hGH-XTEN fusion protein for a human pediatric patient are suitable. In one embodiment, the bolus dose of hGH-XTEN is

(i) between about 0.8 mg/kg and about 1.2 mg/kg, about 1.2 mg/kg and about 1.8 mg/kg, about 1.8 mg/kg and about 2.7 mg/kg, about 2.7 mg/kg and about 4 mg/kg, about 4 mg/kg and about 6 mg/kg, about 0.8 mg/kg and about 1.8 mg/kg, about 0.8 mg/kg and about 2.7 mg/kg, or about 0.8 mg/kg and about 4 mg/kg;

(ii) between about 1.2 mg/kg and about 1.8 mg/kg, about 1.2 mg/kg and about 2.7 mg/kg, about 1.2 mg/kg and about 4 mg/kg, or about 1.2 mg/kg and about 6.3 mg/kg;

(iii) between about 1.8 mg/kg and about 2.7 mg/kg, about 1.8 mg/kg and about 4 mg/kg, or about 1.8 mg/kg and about 6 mg/kg;

(iv) between about 2.7 mg/kg and about 4 mg/kg, about 2.7 mg/kg and about 6 mg/kg; or

(v) between about 4 mg/kg and about 6 mg/kg.

In another embodiment, the bolus dose of hGH-XTEN is selected from the group consisting of about 0.8 mg/kg, about 1.0 mg/kg, about 1.2 mg/kg, about 1.4 mg/kg, about 1.6 mg/kg, about 1.8 mg/kg, about 2.0 mg/kg, about 2.2 mg/kg, about 2.4 mg/kg, about 2.6 mg/kg, about 2.7 mg/kg, about 2.8 mg/kg, about 3 mg/kg, about 3.2 mg/kg, about 3.4 mg/kg, about 3.6 mg/kg, about 3.8 mg/kg, about 4 mg/kg, about 4.2 mg/kg, about 4.4 mg/kg, about 4.6 mg/kg, about 4.8 mg/kg, about 5 mg/kg, about 5.2 mg/kg, about 5.4 mg/kg, about 5.6 mg/kg, about 5.8 mg/kg, about 6 mg/kg, and about 6.3 mg/kg.

In one embodiment, the method comprises administering to a human pediatric patient with PGHD at least two bolus doses of a human growth hormone hGH-XTEN fusion protein, wherein said administration is separated by: at least about 7 days, at least about 10 days, at least about 14 days, at least about 21 days, at least about 28 days, or at least about 30 days. In one other embodiment, the bolus dose is a therapeutically effective bodyweight adjusted bolus dose (as described herein). In one other embodiment, the administering step comprises administering a pharmaceutical composition comprising an effective amount of hGH-XTEN fusion protein comprising the amino acid sequence set forth in FIG. 1 (SEQ ID NO: 1). In another embodiment, the methods described herein comprise the use of a fusion protein having at least about 90%, or at least about 95%, or at least about 96%, or at least about 97%, or at least about 98%, or at least about 99% sequence identity to the sequence as set forth in FIG. 1 (SEQ ID NO: l).

In another embodiment, the administration of bolus doses is separated by: at least about a month, at least about 31 days, at least about 30 days, at least about 29 days, at least about 28 days, at least about 27 days, at least about 26 days, at least about 25 days, at least about 24 days, at least about 23 days, at least about 22 days, at least about 21 days, at least about 20 days, at least about 19 days, at least about 18 days, at least about 17 days, at least about 16 days, at least about 15 days, at least about 14 days, at least about 13 days, at least about 12 days, at least about 11 days, at least about 10 days, at least about 9 days, at least about 8 days, at least about 7 days, at least about 6 days, at least about 5 days, at least about 4 days, at least about 3 days, or at least about 2 days.

In another embodiment, the therapeutically effective bodyweight adjusted bolus doses of hGH-XTEN fusion protein are administered subcutaneously to the human pediatric patient.

In general, a "bolus dose" is a dose administered within a short period of time. In another embodiment, the bolus dose is administered within about 1 to about 30 minutes, about 1 to about 20 minutes, about 1 to about 15 minutes, about 1 to about 10 minutes, or about 1 to about 5 minutes. In one embodiment, the bolus dose is administered within about 1 to about 5 minutes. In one other embodiment, the bolus does is a subcutaneous bolus dose.

In some embodiments, the present disclosure provides methods to establish a dose regimen for the hGH-XTEN pharmaceutical compositions described herein for human pediatric patients. The methods include administration of consecutive doses of a

therapeutically effective amount of the hGH-XTEN composition using variable periods of time between doses to determine that interval of dosing sufficient to achieve and/or maintain the desired parameter, blood level or clinical effect; such consecutive doses of a

therapeutically effective amount at the effective interval establishes the therapeutically effective dose regimen for the hGH-XTEN for a PGHD condition. Thus, in one aspect, the disclosure provides an hGH-XTEN composition for use in a treatment regimen that is therapeutically effective for human growth hormone deficiency (PGHD).

In another aspect, the present disclosure provides an hGH-XTEN fusion protein for use in a treatment regimen for human pediatric growth hormone deficiency (PGHD), which regimen comprises administering a hGH-XTEN fusion protein to a human pediatric patient. In one embodiment, the treatment regimen comprises administering a bolus dose (as described herein) of the hGH-XTEN fusion protein to the human pediatric patient at certain time intervals (as described herein). In one additional embodiment, the treatment regimen comprises subcutaneous administration of the bolus dose of hGH-XTEN. In one embodiment, the regimen comprises administering at least two bolus doses (as described herein) of the hGH-XTEN fusion protein to a human pediatric patient separated by an appropriate time interval (as described herein).

In another embodiment, the present disclosure provides a consecutive dose regimen wherein each bolus dose of the hGH-XTEN is administered every week (or weekly), every two weeks, every three weeks, every four weeks, or monthly.

In one embodiment of the hGH-XTEN composition for use in a treatment regimen, the hGH-XTEN fusion protein comprises the amino acid sequence shown as set forth in FIG. 1 (SEQ ID NO: 1). In one embodiment, the therapeutically effective dose treatment regimen comprises the administration of at least two therapeutically effective bodyweight adjusted bolus doses to a pediatric subject, wherein the doses are administered subcutaneously.

3. hGH-XTEN Equivalency to rhGH

In another aspect, the present invention provides methods of treating human growth hormone deficiency (PGHD) in pediatric patients with a therapeutically effective amount of an hGH-XTEN fusion protein as a bolus dose that is equivalent to, or equivalent to less than, an effective amount of a corresponding hGH (not linked to XTEN) administered daily. In one embodiment, the bolus dose of the fusion protein is equivalent to an amount that is less than between about 4.8 μg hGH/kg/day and about 37 μg hGH/kg/day; or less than or equivalent to about 4.8 μg hGH/kg/day, about 7.4 μg hGH/kg/day, about 1 1.1 μg

hGH/kg/day, about 16.7 μg hGH/kg/day, about 24.7 μg hGH/kg/day, or about 37 μg hGH/kg/day. The approximate mean pediatric rhGH daily dose is 40 μg hGH/kg/day to 43 μg hGH/kg/day. In another embodiment, the bolus dose is a therapeutically effective bodyweight adjusted bolus dose of the hGH-XTEN fusion protein.

In one aspect, the present disclosure provides methods of treating human pediatric growth hormone deficiency (PGHD), comprising administering to a human pediatric patient with PGHD an hGH-XTEN fusion protein at a dosage that is below or less than an equivalent daily dose of recombinant hGH (e.g., a recommended daily dose of rhGH).

In another embodiment, the administration of said bolus doses is separated by at least about 7 days, at least about 10 days, at least about 14 days, at least about 21 days, at least about 28 days, at least about 30 days, or at least about a month.

In one embodiment, the bolus dose of the hGH-XTEN is equivalent to an hGH/kg/day dosage that is less than about 43 μg hGH/kg/day. In another embodiment, the bolus dose of the hGH-XTEN is equivalent to an hGH/kg/day dosage that is less than about 40 μg hGH/kg/day. In another embodiment, the dosage of the hGH-XTEN is equivalent to less than about 39 μg hGH/kg/day, about 38 μg hGH/kg/day, about 36 μg hGH/kg/day, about 34 μg hGH/kg/day, about 32 μg hGH/kg/day, about 30 μg hGH/kg/day, about 28 μg hGH/kg/day, about 26 μg hGH/kg/day, about 25 μg hGH/kg/day, about 24 μg hGH/kg/day, about 22 μg hGH/kg/day, about 20 μg hGH/kg/day, about 18 μg hGH/kg/day, about 17 μg hGH/kg/day, about 16 μg hGH/kg/day, about 14 μg hGH/kg/day, about 12 μg hGH/kg/day, about 11 μg hGH/kg/day, about 8 μg hGH/kg/day, about 7 μg hGH/kg/day, about 6 μg hGH/kg/day, about 5 μg hGH/kg/day, about 4 μg hGH/kg/day, or about 2 μg hGH/kg/day.

In one other embodiment, the bolus dose of the hGH-XTEN is the same or less than the cumulative equivalent hGH/kg/day dosages administered over about 7 days, about 14 days, about 21 days, about 28 days, or about 30 days.

In yet another embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence shown as set forth in FIG. 1 (SEQ ID NO: 1). In other embodiments, the administration is subcutaneous administration.

In one aspect, the bolus dose of the hGH-XTEN may be administered over a range of doses that are equivalent to less than an hGH/kg/day dosage. It should be noted that where reference is made to a bolus dose that is equivalent to less than an hGH/kg/day dosage that is between about a first μg hGH/kg/day and about a second μg hGH/kg/day, the "first μg hGH/kg/day" term may include the first μg hGH/kg/day value and the "second μg

hGH/kg/day" term may include the second μg hGH/kg/day value.

4. hGH-XTEN and IGF-I Levels

The methods of the present disclosure are advantageous with respect to resulting IGF- I levels in the human pediatric patient following treatment with hGH-XTEN fusion protein. A high level of blood IGF-I is undesirable since high IGF-I is believed to be a risk factor for cancer (Svensson et al. J Clin Endocrin Metab. epub September 26, 2012 as

doi: 10.1210/jc.2012-2329). IGF-I generation in humans is largely the result of GH signaling and IGF-I is an important mediator for anabolic actions observed during GH therapy (Le Roith et al. (2001). Endocr Rev 22, 53-74). Accordingly, IGF-I is an important

pharmacodynamic marker for hGH-XTEN fusion protein bioactivity. In practice, IGF-I responses to GH {e.g., daily rhGH therapy) are interpreted in terms of age- and gender- specific normative data (Vance et al. (1999). N Engl J Med 341, 1206-16; Molitch et al. (2011). J Clin Endocrinol Metab 96, 1587-609). The interpretation is most readily done with the use of IGF-I standard deviation scores (IGF-I SDS). Further, pediatric patients with GH deficiency, as with healthy individuals, have a range of baseline IGF-I values in their blood or serum. Because pediatric IGF-I levels vary by age and sex, each patient must be characterized by their individual age and sex-adjusted IGF-I SDS. Accordingly, IGF-I SDS, corrected for baseline at time 0, can be used to examine potential hGH-XTEN fusion protein dose effects on IGF-I responses.

In one aspect, the present disclosure provides methods of treatment of PGHD in which the human pediatric patient maintains an IGF-I response (e.g., as measured by mean IGF-I SDS) in a normal range after administration of the hGH-XTEN fusion protein. For an IGF-I SDS, a normal range is generally between about -1.5 and about 1.5 but can also be between about -2.0 and about 2.0.

It should be noted that where reference is made to an IGF-I SDS between about a first value (e.g., -2.0) and about a second value (e.g., 2.0), the "first value" may include the first value and the "second value" may include the second value.

In one embodiment, the present disclosure provides a method of treating pediatric growth hormone deficiency (PGHD) in a human pediatric patient by administering an hGH- XTEN fusion protein to the patient, wherein the human patient has a serum IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 following administration. In one embodiment, the method comprises administering the hGH-XTEN fusion protein to the pediatric patient as a bolus dose (as described herein). In another embodiment, the bolus dose is a therapeutically effective bodyweight adjusted bolus dose. In other embodiments, the pediatric patient has a serum IGF-I SDS of greater than about -2.0, greater than about - 1.5, greater than about -1.0, greater than about -0.5, or greater than about 0, greater than about 0.5, greater than about 1.0, greater than about 1.5, greater than about 1.6, greater than about 1.7, greater than about 1.8, or greater than about 1.9 following administration of the hGH-XTEN.

In another embodiment, the bolus dose of the hGH-XTEN is effective to maintain the pediatric patient's serum IGF-I standard deviation score (SDS) (a) between about -2.0 and about 2.0, or (b) between about 0 and about 2.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 1 1 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, or at least about 30 days following administration of the bolus dose. In another embodiment, administration of multiple consecutive hGH-XTEN bolus doses is effective to maintain the pediatric patient's serum IGF-I standard deviation score (SDS) (a) between about -2.0 and about 2.0, or (b) between about 0 and about 2.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, or at least about 30 days between administrations of the bolus doses. In the foregoing embodiment, the bolus doses are administered weekly, every two weeks, every three weeks, or monthly.

In another embodiment, administration of multiple consecutive hGH-XTEN bolus doses is effective to maintain the pediatric patient's mean serum IGF-I standard deviation score (SDS) (a) between about -2.0 and about 2.0, or (b) between about -1.0 and about 2.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, or at least about 30 days between administrations of the bolus doses. In the foregoing embodiment, the bolus doses are administered weekly, every two weeks, every three weeks, or monthly.

In another embodiment, administration of multiple consecutive hGH-XTEN bolus doses is effective to maintain the pediatric patient's serum IGF-I standard deviation score (SDS) (a) above about -2.0, or (b) above about 0, or (c) above about 1.0, or (d) above about 1.5 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, or at least about 30 days between administrations of the bolus doses. In the foregoing embodiment, the bolus doses are administered weekly, every two weeks, every three weeks, or monthly. In another embodiment, administration of multiple consecutive hGH-XTEN bolus doses is effective to maintain the pediatric patient's serum IGF-I standard deviation score (SDS) (a) below about 1.5, or (b) below about 2.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, or at least about 30 days between administrations of the bolus doses. In the foregoing embodiment, the bolus doses are administered weekly, every two weeks, every three weeks, or monthly.

In another embodiment, administration of multiple consecutive hGH-XTEN bolus doses is effective to maintain the pediatric patient's change in mean maximum serum IGF-I standard deviation score (SDS) compared to baseline SDS (a) between about 0.5 and 3.0, or (b) between about 1.0 and 2.5 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, or at least about 30 days between administrations of the bolus doses. In the foregoing embodiment, the bolus doses are administered weekly, every two weeks, every three weeks, or monthly.

In another embodiment, the administering step comprises administering a

pharmaceutical composition comprising an effective amount of hGH-XTEN fusion protein comprising the amino acid sequence set forth in FIG. 1 (SEQ ID NO: 1).

In one other aspect, the present disclosure provides methods of treating pediatric patients by administering an hGH-XTEN fusion protein to provide a normal serum IGF-I level in the pediatric patient. In one embodiment, the hGH-XTEN fusion protein is administered as a bolus dose (as described herein). In another embodiment, at least two bolus doses are administered separated by a time interval (as described herein). In one other embodiment, the bolus dose(s) is a therapeutically effective bodyweight adjusted bolus dose of the fusion protein. In an additional other embodiment, the administration of said bolus dose(s) of the hGH-XTEN results in a normalization of serum IGF-I levels in the a pediatric subject for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, at least about 30 days, or at least about a month following administration of the bolus dose. In one other embodiment, a normal serum IGF-I level is characterized by a serum IGF-I standard deviation (SD) that is above about -2.0; above about -1.5; above about -1.0; above about 0; above about 0.5; above about 1.0; or above about 1.5. In another embodiment, a normal serum IGF-I level is characterized by a serum IGF-I standard deviation (SD) that is between about -1.5 and about 1.5; between about -1.5 and about 1.0; between about -1.5 and about 0.5; between about -1.5 and about 0; between about -1.5 and about -0.5; and between about - 1.5 and about -1.0.

In an additional embodiment, the extent of normalization of IGF-I serum levels is dependent on the dose of the therapeutically effective bodyweight adjusted bolus dose of hGH fusion protein. In one other embodiment, the duration of the IGF-I normalization increases with the therapeutically effective bodyweight adjusted bolus dose of hGH fusion protein.

In some embodiments, methods of the present disclosure provide a particular advantage in that the administration of hGH-XTEN fusion protein provides an observable and prolonged IGF-I response in the human pediatric patient (e.g., as measured by IGF-I SDS) that is not accompanied by, or at the expense of, over-exposure to high levels of IGF-I, which is undesirable. In other words, the IGF-I response is maintained at an elevated level that is still considered acceptable by current standards, e.g., as indicated by an IGF-I SDS of 1.5 or less, or an IGF-I SDS of 2.0 or less.

5. Plasma concentration of hGH-XTEN fusion protein

In another aspect, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in a human pediatric patient by administering an hGH-XTEN fusion protein to the patient, wherein the patient has a plasma concentration of said fusion protein of at least about 10 ng/mL following administration. In one

embodiment, the method comprises administering the hGH-XTEN fusion protein to the pediatric patient as a bolus dose (as described herein). In another embodiment, the bolus dose of the hGH-XTEN is a therapeutically effective bodyweight adjusted bolus dose (as described herein). In one embodiment, the bolus dose is selected from the group consisting of about 0.8 mg/kg, about 1.0 mg/kg, about 1.2 mg/kg, about 1.4 mg/kg, about 1.6 mg/kg, about 1.8 mg/kg, about 2.0 mg/kg, about 2.2 mg/kg, about 2.4 mg/kg, about 2.6 mg/kg, about 2.7 mg/kg, about 2.8 mg/kg, about 3 mg/kg, about 3.2 mg/kg, about 3.4 mg/kg, about 3.6 mg/kg, about 3.8 mg/kg, about 4.0 mg/kg, about 4.2 mg/kg, about 4.4 mg/kg, about 4.6 mg/kg, about 4.8 mg/kg, about 5.0 mg/kg, about 5.2 mg/kg, about 5.4 mg/kg, about 5.6 mg/kg, about 5.8 mg/kg, about 6.0 mg/kg, and about 6.3 mg/kg. In another embodiment, the bolus dose of the hGH-XTEN is effective to maintain a plasma concentration of the fusion protein of at least about 10 ng/mL for: at least about 5 days, at least about 7 days, at least about 10 days, at least about 14 days, at least about 20 days, at least about 25 days, at least about 30 days, or at least about a month. In another embodiment, the bolus dose is effective to maintain a plasma concentration of the fusion protein of at least about 100 ng/mL for: at least about 5 days, at least about 7 days, at least about 10 days, at least about 14 days, or at least about 20 days. In one other embodiment, the administering step comprises

administering a pharmaceutical composition comprising an effective amount of hGH-XTEN fusion protein comprising the amino acid sequence set forth in FIG. 1 (SEQ ID NO: 1).

6. Absence of Side Effects

In one embodiment, the present disclosure provides a method of treating human pediatric growth hormone deficiency (PGHD) in a human pediatric patient comprising administering to the patient an hGH-XTEN fusion protein in the absence of one or more side effects. In one other embodiment, the absence of one or more side effects is the absence of a clinically significant level of one or more side effects. In another embodiment, the one or more side effects that are absent are selected from the group consisting of headache, arthalgia, myalgia, edema, nausea, and muscle fatigue after administration of the fusion protein. As used herein, "clinically significant level of a side-effect" means that the side- effects) is/are not unexpected or is/are not serious adverse event(s). Side-effects that are mild and transient, even if one of headache, arthalgia, myalgia, edema, nausea, and muscle fatigue or those otherwise known to be associated with the administration of growth hormone, would not be considered a clinically significant level. In one embodiment, the method comprises administering the hGH-XTEN fusion protein to the pediatric patient as a bolus dose (as described herein). In another embodiment, the bolus dose of the hGH-XTEN fusion protein is a therapeutically effective bodyweight adjusted bolus dose (as described herein). In one other embodiment, the bolus dose is administered subcutaneously. In one other embodiment, the administering step comprises administering a pharmaceutical composition comprising an effective amount of hGH-XTEN fusion protein comprising the amino acid sequence set forth in FIG. 1 (SEQ ID NO: 1).

7. Parameters following Administration

In one embodiment, the present disclosure provides a method for achieving a beneficial effect in a human pediatric patient with growth hormone deficiency, comprising the step of administering to the pediatric patient a therapeutically-effective amount of a hGH- XTEN fusion protein wherein said administration results in the improvement of one or more biochemical or physiological parameters or clinical endpoints associated with a growth hormone-related disease, disorder or condition, including a PGHD (as described herein). The effective amount produces a beneficial effect in helping to treat (e.g., cure or reduce the severity) the deleterious effects of a growth hormone-related disease, disorder or condition. In some cases, the method for achieving a beneficial effect includes administering a therapeutically effective amount of a hGH-XTEN fusion protein composition to treat a pediatric patient with a growth hormone-related disease, disorder, or condition, including a PGHD (as described herein).

In some embodiments, methods described herein include the administration to a human pediatric patient successive or consecutive doses of a therapeutically effective amount of the hGH-XTEN for a period of time sufficient to achieve and/or maintain the desired parameter or clinical effect, and such consecutive doses of a therapeutically effective amount establishes the therapeutically effective dose regimen for the hGH-XTEN; i.e., the schedule for consecutively administered doses of the fusion protein composition, wherein the doses are given in therapeutically effective amounts to result in a sustained beneficial effect on any clinical sign or symptom, aspect, measured parameter or characteristic of a metabolic disease state or condition, including, but not limited to, those described herein. In one embodiment of the method, the parameters include but are not limited to mean (SD) height standard deviation score (HT-SDS), changes in height velocity, IGF-I concentration, ratio of IGF - I/IGFBP-3, IGFBP3 concentration, change in weight, lean body mass, change in body mass index, total body fat (adipose fat/tissue), trunk fat, response to insulin challenge, rate of division of chondrocytes, chondrocyte numbers, bone density, bone age, bone growth, bone turnover, increase in epiphyseal plate width, reduction in cholesterol, reduction in

triglycerides, and reduction in LDL. In another embodiment of the method, the

administration to a human pediatric patient of successive or consecutive doses of a therapeutically effective amount of the hGH-XTEN results in a beneficial effect in two or more of the parameters including, but not limited to mean (SD) height standard deviation score (HT-SDS), changes in height velocity, IGF-I concentration, ratio of IGF-I/IGFBP-3, IGFBP3 concentration, change in weight, lean body mass, change in body mass index, total body fat (adipose fat/tissue), trunk fat, response to insulin challenge, rate of division of chondrocytes, chondrocyte numbers, bone density, bone age, bone growth, bone turnover, increase in epiphyseal plate width, reduction in cholesterol, reduction in triglycerides, and reduction in LDL.

Height velocity data in pediatric patients treated with recombinant human growth hormone (rhGH) has been compiled into various databases. The National Cooperative Growth Study (NCGS) database contains 220,000 patient-years of growth data on children receiving rhGH therapy. The NCGS database was initiated in December 1985 to collect data in children treated with rhGH for evaluation of safety and efficacy. Anonymous data were entered by clinical investigators in the US including date of birth, sex, height, weight, etiology of short stature, peak serum GH response to stimulation testing, Tanner pubertal stages, parental heights, and GH dose for patients treated with Genentech's rhGH products (Shulman, DI, et al. Int J Pediatr Endocrinol. 2013; 2013(1): 2). It has been shown that height velocity observed during the first year of treatment ("first year height velocity") with GH is the major determinant of the second pre-pubertal year growth response to GH in small for gestational age (SGA) children (Ranke MB, et al. J Clin Endocrinol Metab. 2003;88: 125- 131). The first year height velocity can be measured in the pediatric patient over a period of 3 months, 4 months, 6 months, or other period up to 12 months to ascertain the annualized first year height velocity, expressed as "cm/yr".

In other embodiments of the method for achieving a beneficial effect in a human pediatric patient with growth hormone deficiency, the methods comprise the step of administering to the pediatric patient a therapeutically-effective amount of a hGH-XTEN fusion protein wherein said administration results in the improvement in height velocity rate in the pediatric patient. In one embodiment of the method, the method is effective to achieve aheight velocity equivalent to 7 cm/yr to 12 cm/yr in a pediatric patient. In another embodiment of the method, the method is effective to achieve a height velocity equivalent to 8 cm/yr to 11 cm/yr in a pediatric patient. In one embodiment, the height velocity is achieved (or determined) after at least about 3 months, or at least about 6 months, or at least about 12 months of dosing in the pediatric patient. In another embodiment, the height velocity achieved is a first year height velocity. In another embodiment, the method is not inferior to the height velocity achieved with daily injections of hGH not linked to XTEN over the same period and administered using comparable equivalent doses on a molar basis. In another embodiment, the method is effective to maintain the pediatric patient's annualized height velocity after at least 3 months of dosing within 10%, 20%, or 30% of that compared to the height velocity achieved with daily injections of an hGH not linked to XTEN of an equivalent amount, on a molar basis, over the same period. In one embodiment of the foregoing, the pediatric patients administered daily injections of hGH not linked to XTEN receive a dose of at least about 25, at least about 30, at least about 33, at least about 35 μg rhGH/kg/day, at least at least about 37 μg rhGH/kg/day, or at least about 43 μg rhGH/kg/day. In the foregoing embodiments of this paragraph, the bolus dose of the hGH-XTEN fusion protein is a therapeutically effective bodyweight adjusted bolus dose comprising between about 0.8 mg/kg and about 6.3 mg/kg of hGH-XTEN fusion protein. In another embodiment, the bolus dose of the hGH-XTEN fusion protein is a therapeutically effective bodyweight adjusted bolus dose comprising between about 0.8 mg/kg and about 7.0 mg/kg of hGH-XTEN fusion protein. In another embodiment, the bolus doses are administered every week, every two weeks, every three weeks, semimonthly or monthly. In another embodiment, the pediatric patients are administered bolus doses of about 1.15 mg/kg of hGH-XTEN fusion protein weekly, or about 2.5 mg/kg of hGH-XTEN fusion protein every two weeks, or about 5.0 mg/kg of hGH-XTEN fusion protein monthly. In another embodiment, the pediatric patients are administered bolus doses selected from about 0.8 mg/kg to about 1.5 mg/kg, about 1.8 mg/kg to about 3.2 mg/kg, or about 3.5 mg/kg to about 6.3 mg/kg. In a preferred

embodiment, the pediatric patients are administered bolus doses of at least about 5.0 mg/kg of hGH-XTEN fusion protein monthly.

In another embodiment of the regimen, the human pediatric patient achieves an improvement after two or more bolus doses in at least one parameter selected from bone density, bone growth, and increase in epiphyseal plate width. In one other embodiment, the foregoing improvement(s) is at least about 10%, or at least about 20%, or at least about 30%, or at least about 40%, or at least about 50%, or at least about 60%, or at least about 70%, or at least about 80%, or at least about 90% compared to a human pediatric patient not receiving human growth hormone. In another embodiment, the foregoing percentage improvement(s) is similar to, or not inferior to, an improvement achieved by an hGH not linked to XTEN and administered daily using daily dosage equivalent amounts of hGH.

8. hGH-XTEN Medicaments

In another embodiment, the present disclosure provides an hGH-XTEN fusion protein for use as a medicament, or for the treatment of PGHD in pediatric patients. In another embodiment, the present invention provides the use of an hGH-XTEN fusion protein for the manufacture of a medicament for treating PGHD in a human pediatric patient with PGHD. In one other embodiment, the present invention provides the use of the fusion protein having the sequence set forth in FIG. 1 (SEQ ID NO: 1) in the manufacture of a medicament for the treatment of PGHD in pediatric patients. In other embodiments, the hGH-XTEN fusion protein is provided as a bolus dose (as described herein). In another embodiment, the bolus dose is a therapeutically effective bodyweight adjusted dose. In another embodiment, the medicament is formulated for subcutaneous administration. In one other embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence shown as set forth in FIG. 1 (SEQ ID NO: 1).

9. Treatment of Indicia of pediatric GH-related conditions

In another aspect, the present invention provides hGH-XTEN fusion protein-based therapeutic agents for treating diseases or conditions related to pediatric growth hormone deficiency (PGHD) in a pediatric patient. For the prevention, treatment or reduction in the severity of a given disease or condition, the appropriate dosage of a therapeutic agent of the invention will depend on the type of disease or condition to be treated, as defined above, the severity and course of the disease or condition, whether the agent is administered for therapeutic purposes, previous therapy, the pediatric patient's clinical history and response to the agent, and the discretion of the attending physician.

In another aspect, the present disclosure provides a method for the delaying or slowing down of the progression of a disease or condition related to PGHD in a pediatric patient. In one embodiment, the method comprises administering to pediatric subject diagnosed with the disease, condition, or disorder, an effective amount of an hGH-XTEN fusion protein. In another aspect, the present disclosure provides a method for treating or ameliorating indicia of a disease or condition related to PGHD. In one embodiment, the method comprises administering an effective amount of an hGH-XTEN fusion protein to a pediatric subject at risk of the disease or condition, wherein the hGH-XTEN fusion protein is effective against the development of indicia of the disease or condition.

In one additional aspect, the hGH-XTEN fusion proteins provide an ameliorative effect against the development of, or the progression of, clinical and/or histological and/or biochemical and/or pathological indicia (including both symptoms and signs) of diseases or conditions related to PGHD in a human pediatric patient. In one embodiment, the disease or condition is PGHD. In one embodiment, the indicia in pediatric patients include small stature, an increased level of body fat (especially central or trunk adiposity, i.e, the waist), slow rate of growth of all body parts, leveling off or falling away from an established growth curve for height, delayed bone age, decreased IGF-I SDS, and below average height SDS. In another embodiment, the pediatric subject is at risk for a disease of condition related to PGHD. In general, a pediatric subject at risk will previously have incurred some damage to the pituitary gland and/or the hypothalamus. In one embodiment, the pediatric subject at risk was previously diagnosed as having a tumor associated with the pituitary gland, and/or underwent surgery, chemotherapy, or radiation therapy to treat the tumor. In another embodiment, the pediatric subject at risk previously had or presently has a reduced blood supply to the pituitary gland. In one other embodiment, the pediatric subject at risk previously suffered cranial ablation or has a history of head trauma. In some embodiments, the pediatric subject at risk previously or presently suffers from a hypothalamic-pituitary disease or disorder.

The efficacy of the treatment of diseases and conditions described herein (including PGHD) can be measured by various assessments commonly used in evaluating PGHD in pediatric patients. For example, the health of hormone-secreting glands can be evaluated by, but not limited to, e.g., IGF-I standard deviation score (SDS), mean (SD) height standard deviation score (HT-SDS), growth hormone stimulation test (GHST), growth hormone releasing hormone (GURH), stimulation tests, monitoring or measurement of endogenous hHG pulses, IGF-I levels, IGF-I binding protein levels, other blood or biochemical tests (e.g., total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglyceride, and lipids).

In one additional aspect, the present disclosure provides methods of increasing the efficacy of human growth hormone (hGH) therapy in a human pediatric patient. In another aspect, the present disclosure provides methods of determining a subsequent dose of an hGH- XTEN fusion protein administered over a subsequent dosage period when treating a human pediatric patient with PGHD with the hGH-XTEN fusion protein. The "dosage period" means the time between the administration of a bolus dose (e.g., initial dose) and the next successive administration of a bolus dose (e.g., subsequent dose). The dosage period may change with one or more further successive dose or doses, or may remain constant.

In one embodiment, the foregoing methods of increasing efficacy comprise the step of monitoring the IGF-I standard deviation score (SDS) in a plasma or serum sample obtained from the pediatric patient during an initial dosage period of administration of an initial dose of human growth hormone-XTEN (hGH-XTEN) fusion protein. In one embodiment, the hGH-XTEN fusion protein comprising an amino acid sequence having at least about 90% sequence identity to SEQ ID NO: 1. In another embodiment, the method further comprises the step of determining a subsequent dose of hGH-XTEN fusion protein administered over a subsequent dosage period based on the IGF-I SDS observed during the initial dosage period. In one additional embodiment, the method further comprises administering the subsequent dose over a subsequent dosage period. In one other embodiment, the subsequent dose improves the efficacy of the treatment during the subsequent dosage period. In another embodiment, the subsequent dose is higher, lower, or equivalent to the initial dose. The initial dose or subsequent dose may be any of the bolus doses described herein. In one additional embodiment, the subsequent dosage period is longer, shorter, or equivalent to the initial dosage period. The initial dosage period or subsequent dosage period may be any of the periods of time described herein (e.g., weekly, every two weeks, semimonthly, every three weeks, monthly, etc., or every 7 days, every 10 days, every 14 days, every 21 days, every 30 days, etc.).

VII). DOSAGE FORMS AND PHARMACEUTICAL COMPOSITIONS

In another aspect, the present disclosure provides bolus doses or dosage forms comprising an hGH-XTEN fusion protein described herein.

In one embodiment, the bolus dose or dosage of an hGH-XTEN fusion protein comprises a therapeutically effective bodyweight adjusted bolus dose for a human pediatric patient. In one other embodiment, the bolus dose or dosage comprises between about 0.8 mg/kg and about 6.3 mg/kg of hGH-XTEN fusion protein. Other bolus doses are described herein.

In other embodiments, the bolus dose or dosage is (i) for use in treating human PGHD in a pediatric subject in need; and/or (ii) formulated for subcutaneous administration. In one other embodiment, the hGH-XTEN fusion protein comprises the amino acid sequence shown as set forth in FIG. 1 (SEQ ID NO: 1). In one embodiment, the bolus dose or dosage form is a pharmaceutical composition comprising the fusion protein having the sequence as set forth in FIG. 1 (SEQ ID NO: l) and a pharmaceutically acceptable carrier.

In another embodiment, the present disclosure provides kits, comprising packaging material and at least a first container comprising the pharmaceutical composition of the foregoing embodiment and a label identifying the pharmaceutical composition and storage and handling conditions, and a sheet of instructions for the preparation and/or administration of the pharmaceutical compositions to a pediatric subject.

In one additional aspect, the present disclosure provides compositions, pharmaceutical compositions, and dose amounts of an hGH-XTEN fusion protein. In one other embodiment, the pharmaceutical composition or dose amount comprises a fusion protein having the sequence as set forth in FIG. 1 (SEQ ID NO: 1), or a sequence having at least about 90%, at least about 91%, or at least about 92%, or at least about 93%, or at least about 94%, or at least about 95%), or at least about 96%, or at least about 97%, or at least about 98%, or at least about 99%), sequence identity to the sequence of SEQ ID NO: 1. In another embodiment, the dose amount is for a human pediatric patient based upon the weight of the patient. The weight of the pediatric human patient can range from about 10 kg to about 50 kg. In one additional embodiment, the hGH-XTEN fusion protein is provided in the pharmaceutical composition, composition, or dose amount as a certain quantity. In one other embodiment, the pharmaceutical composition or dose amount further comprises a pharmaceutically acceptable carrier.

In one embodiment, the pharmaceutical composition is administered at a

therapeutically effective dose. In another embodiment, the pharmaceutical composition is administered using multiple consecutive doses using a therapeutically effective dose regimen (as defined herein) for the length of the dosing period.

A therapeutically effective amount of the hGH-XTEN varies according to factors such as the disease state, age, sex, and weight of the individual, and the ability of the fusion protein to elicit a desired response in the individual. A therapeutically effective amount is also one in which any toxic or detrimental effects of the hGH-XTEN are outweighed by the therapeutically beneficial effects.

It should be noted that where reference is made to a composition, pharmaceutical composition or dose amount comprising an amount of hGH-XTEN fusion protein between about a first mg and about a second mg, the "first mg" term may include the first mg value and the "second mg" term may include the second mg value.

In another aspect, the present disclosure provides hGH-XTEN fusion proteins for use in a pharmaceutical regimen or therapeutically effective dose regimen for the treatment of PGHD. In one embodiment, the hGH-XTEN fusion protein is for use in a regimen comprising a bolus dose of the fusion protein to treat a pediatric patient. In an additional embodiment, the regimen comprises the step of determining the amount of the hGH-XTEN fusion protein needed to achieve an IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 in the pediatric patient.

In one other embodiment, the regimen comprises a therapeutically effective bodyweight adjusted bolus dose. In another embodiment, the regimen comprises a bolus dose of the fusion protein that is between about 0.8 mg/kg and about 6.3 mg/kg. In one other embodiment, the regimen comprises the administration of consecutive bolus doses of fusion protein. In one embodiment, the administration of consecutive bolus doses is about every week, about every two weeks, about every three weeks, or about every month. In one additional embodiment, the fusion protein comprises an amino acid sequence having at least about 90% sequence identity to SEQ ID NO: 1. In one embodiment, the regimen comprises subcutaneous administration of the bolus dose of the fusion protein. In another embodiment, the regimen is effective to treat PGHD in a pediatric patient.

VIII). ARTICLES OF MANUFACTURE

In one aspect, the present disclosure also provides kits and articles of manufacture containing materials useful for the treatment, prevention and/or diagnosis of disease (e.g., PGHD) in pediatric patients. In another embodiment, the invention provides kits, comprising packaging material and at least a first container comprising a dosage form or pharmaceutical composition of the foregoing embodiment and a label identifying the dosage form or pharmaceutical composition and storage and handling conditions, and a sheet of instructions for the reconstitution and/or administration of the dosage form or pharmaceutical

compositions to a pediatric subject. In one other embodiment, the kit includes a container and a label, which can be located on the container or associated with the container. The container may be a bottle, vial, syringe, cartridge (including autoinjector cartridges), or any other suitable container, and may be formed from various materials, such as glass or plastic. The container holds a composition having an hGH-XTEN fusion protein as described herein, and may have a sterile access port. Examples of containers include a vial with a stopper that can be pierced by a hypodermic injection needle. The kits may have additional containers that hold various reagents, e.g., diluents, preservatives, and buffers. The label may provide a description of the composition as well as instructions for the intended use in pediatric patients.

In one other aspect, the container is a pre-filled syringe. In one embodiment, the syringe is pre-filled with a composition having an hGH-XTEN fusion protein as described herein. In one additional aspect, the present invention provides containers of the composition having a hGH-XTEN fusion protein as described herein, wherein the container is suitable for autoinjection of the composition. In one embodiment, the container is a cartridge. In another embodiment, the container is a cartridge in an autoinjection pen. Those of ordinary skill in the art will appreciate that other suitable autoinjection devices may be used for the present invention. In some embodiments, the autoinjection device comprises a spring-loaded syringe within a cylindrical housing that shields the needle tip prior to injection. In one embodiment, the pediatric patient depresses a button on the device and the syringe needle is automatically inserted to deliver the contents.

In another embodiment, the device is a gas jet autoinjection device. In other embodiments, the gas jet device comprises a cylinder of pressurized gas but the needle is absent. Upon activation, the device propels a fine j et of liquid through the skin without the use of a needle. In one other embodiment, the device is an iontophoresis device or electromotive drug administration (EMDA) device (e.g., use of a small electric charge to deliver an agent through the skin without the use of a needle).

The kit has at least one container that includes a composition comprising an hGH- XTEN fusion protein described herein as the active agent. The container may comprise an hGH-XTEN fusion protein dosage form or a pharmaceutical composition. A label may be provided indicating that the dosage form or composition may be used to treat a disease in a pediatric patient. The label may also provide instructions for administration to a pediatric subject in need of treatment. The kit may further contain an additional container having a pharmaceutically-acceptable buffer, such as bacteriostatic water for injection (BWFI), phosphate-buffered saline, Ringer's solution and dextrose solution. Finally, the kit may also contain any other suitable materials, including other buffers, diluents, filters, needles, and syringes.

In one aspect, the present disclosure provides a kit comprising a container which holds a pharmaceutical composition for administration to a human pediatric patient comprising a human growth hormone-XTEN (hGH-XTEN) fusion protein. In one embodiment, the hGH-XTEN fusion protein comprises an amino acid sequence having at least about 90% sequence identity to the sequence set forth in FIG. 1 (SEQ ID NO: 1). In another embodiment, the kit further comprises a package insert associated with said container. In one other embodiment, the package insert indicates that said composition is for the treatment of growth hormone deficiency by administration of more than one dose of the composition. In one embodiment, the administration is an administration of an initial dose of between about 0.8 mg/kg and about 6.3 mg/kg of the hGH-XTEN and a plurality of subsequent doses of the hGH-XTEN in an amount of between about 0.8 mg/kg and about 6.3 mg/kg. In another embodiment, the doses are separated in time from each other by at least about 7 days. The package insert may further indicate different doses, dose ranges, and times between doses as described herein. The following are examples of methods, treatment regimens, and compositions of the invention. It is understood that various other embodiments may be practiced, given the general description provided above.

EXAMPLES Phase lb/2a Studies

In a Phase lb Study in pre-pubertal moderate GHD children, VRS-317

concentrations, IGF-I and IGFBP-3 responses were proportional to dose, with drug concentrations and increases in IGF-I and IGFBP-3 still present 30 days after a single subcutaneous injection at different concentrations (from about 0.80 to about 6.0 mg/kg) equivalent to about 4.8 to about 37 μg rhGH/kg/day taken for 30 days. VRS-317 dosing did not come at the expense of overexposure to IGF-I. Only 2 patients at the 3.5 mg/kg semimonthly dose had transient IGF-I SDS values above 2.0 and none above 3.0. In sum, single dose VRS-317 administration was found to be safe and well tolerated, with minimal injection site discomfort.

In a Phase 2a Study in pre-pubertal moderate GHD children, repeat dosing with VRS-

317 was found to be safe and well tolerated. IGF-I increases over baseline were maintained without IGF-I overexposure when a total monthly dose of 5.0 mg/kg VRS-317 was given at weekly, semi-monthly, or monthly intervals. The mean annualized 6 month height velocities (a.k.a., growth velocities) from GHD children in the Phase 2a were found to be comparable to the historical age-matched controls administered at a comparable dose of daily rhGH (33 μg rhGH/kg/day). Overall, data from the Phase 2a clinical trial of GHD children indicate that over a 6 month treatment period, VRS-317 has a comparable safety and efficacy profile to historical studies of daily rhGH administered at comparable doses.

Extension Study

An Extension Study was conducted to investigate the long term safety of extended treatment with somavaratan (VRS-317). Data is initially reported for an additional 6 months beyond the initial 6 month Phase 2a treatment window. Data is also reported from patients who had received an additional total of 12 months beyond the initial 6 month treatment period.

Treatment with VRS-317 for 6-12 months

Methods

An analysis of repeat dosing of VRS-317 was conducted to determine the safety, tolerability, and height velocity responses after 12 months of VRS-317 treatment. Patients initially were selected for treatment with VRS-317 and monitored in a Phase 2a Study generally as described in WO/2014/164568 (U.S. Patent Application No. 14/771,445).

Moderate GHD patients receiving VRS-317 at 5.0 mg/kg monthly, 2.5 mg/kg semi-monthly, or 1.15 mg/kg weekly in the Phase 2a Study (FIG. 2) were enrolled in an Extension Study for an additional 6 months of treatment (FIG. 3). Approximately 95% of patients from the Phase 2a Study elected to continue treatment and enroll in the Extension Study.

A PK/PD model for VRS-317 was built on results from the Phase lb Study (FIG. 4) indicating that a change in VRS-317 treatment from 2.5 mg/kg semi-monthly to 3.5 mg/kg semi-monthly would increase average IGF-I SDS by nearly a full SD, bringing this measurement into the upper half of the normal range (FIG. 5 and FIG. 6). Daily growth hormone therapy dosed at 40 μg/kg/day in similar moderate GHD patients caused a comparable IGF-I response in a controlled U.S. study (FIG. 7). Therefore, patients dosed at 1.15 mg/kg weekly in the Phase 2a Study were switched on their next visit in the Extension Study to 3.5 mg/kg semi-monthly. The 3.5 mg/kg semi-monthly dose was selected based upon confirmation of the PK/PD model from the Phase lb Study. Of these patients switched to 3.5 mg/kg semi-monthly, 5 switched on the day 1 visit of the Extension Study and 15 switched on the month 3 visit of the Extension Study. Throughout the 6 months in the Extension Study, dose administration was performed at home by the parent or caregiver with nearly complete compliance with the schedule of dosing (monthly or semi-monthly).

Results

The safety profile of VRS-317 in all patients over 12 months of continuous VRS-317 therapy was comparable to daily growth hormone therapy (FIG. 3). There were no unexpected or serious adverse events and the few events noted were mild and transient. The number of adverse events declined in the second 6 months of therapy and only a minority of patients reported any adverse events. There were no new adverse events or increases in adverse events for patients switching to the 3.5 mg/kg VRS-317 semi-monthly dose. There were only minimal transient excursions of IGF-I SDS above 2 and no excursions above 3.

As part of the Extension Study, the dosing for a subset of the patient population was increased such that 20 patients on the 1.15 mg/kg weekly dose in Phase 2a were switched to 3.5 mg/kg semi-monthly, the same dose that will also be used in the upcoming global Phase 3 trial. This dose change caused IGF-I levels to increase into the upper part of the therapeutic range moving the IGF-I SDS from -0.4 for the 2.5 mg/kg semi-monthly dose to +0.5 for the 3.5 mg/kg semi-monthly dose (FIG. 6). As seen in FIG. 9, this subset of patients (treated with 1.15 mg/kg weekly for 6 months and then switched to 3.5 mg/kg semi-monthly for 6 months) had a change in mean annualized height velocity from 7.5 cm/yr to 9.3 cm/yr, nearly a 2 cm/yr increase in height velocity. Typically, a decrease in height velocity in the second 6 months of treatment would have been expected as observed for daily rhGH therapy (FIG. 10).

The height velocities measured after 12 months of continuous VRS-317 therapy for the patients who remained on 5 mg/kg monthly and 2.5 mg/kg semi-monthly doses in the Extension Study were not significantly different from those observed in the same patients at 3, 6, and 9 months (FIG. 10). In particular, as shown in FIG. 10, the height velocity for patients completing 12 months of treatment at 2.5 mg/kg semi-monthly was 8.5 cm/yr, which is consistent with the first year growth rate for moderate GHD patients receiving the highest labeled dose of Genotropin^® or Norditropin^®.

Conclusions

VRS-317 was safe, well tolerated, and effective after 12 months of treatment in prepubertal children with GHD. All regimens provided comparable IGF-I responses with minimal excursions (> IGF-I SDS of 2). A PK/PD model confirmed the predicted change in average IGF-I SDS over dosing interval depending upon VRS-317 dose. Adjusting VRS-317 dose from 2.5 mg/kg semi-monthly to 3.5 mg/kg semi-monthly resulted in expected increase in IGF-I response without overexposure and increase in height velocity demonstrating dose response. Less waning of the growth response was observed over the first 12 months of VRS-317 treatment than typically observed with daily rhGH therapy. The lack of waning in the growth rates over 12 months suggests that VRS-317 may be providing a more consistent and measured growth response in GHD children compared to daily growth hormone therapy. Furthermore, these results clearly demonstrate a dose response in both IGF-I levels and height velocity, providing further confirmation of the selected Phase 3 VRS-317 dose of 3.5 mg/kg semi-monthly (FIG. 11).

Treatment with VRS-317 for 12-18 months

Methods

Patients in the aforementioned Extension Study continued treatment for an additional 12-18 plus months as illustrated in FIG. 12 to evaluate whether somavaratan at the Phase 3 dose (3.5 mg/kg) given twice-monthly between 12-18 months of treatment can continue to offset the decrease in height velocity (HVs) commonly seen during the second year of daily rhGH treatment.

Results

The vast majority (63 of 64) enrolled pre-pubertal GHD children completed the 6- month study of weekly, twice-monthly, or monthly dosing (5.0 mg/kg per month) and 56 subjects have completed 18 months of treatment. The mean age at Month 18 was 9.28 years; all but 2 subjects remained prepubertal. After increasing the dose in the twice-monthly dose group (n=17) from 2.5 to 3.5 mg/kg, somavaratan led to increased mean peak IGF-I SDS from -0.30 ± 1.2 to 0.32 ± 1.6 between 12-18 months (P=0.007, paired t-test; FIG. 13). At the 3.5 mg/kg dose, there were three IGF-I SDS > 2 and none > 3.

The anticipated decline in 2nd year height velocity (HV) was not observed with the 3.5 mg/kg dose. In particular, as shown in FIG. 14, during the initial 12 months of treatment, mean HV was 7.9 ± 2.1 cm/year and 8.5 ± 2.1 cm/year for subjects in the 5 mg/kg monthly and 2.5 mg/kg twice-monthly dose groups, respectively. After 18 total months of treatment, the last 6 months at 3.5 mg/kg twice-monthly, the mean (annualized) 12-18 month HV was 8.1 ± 2.4 cm/year and 8.3 ± 1.8 cm/ year for each dose group, respectively. Thus, FIG. 14 illustrates that the anticipated decline in height velocity in the second year of treatment seen with daily growth hormone therapy was not observed with 3.5 mg/ kg of somavaratan dosed twice-monthly.

Treatment-related adverse events (AEs) between 12-18 months were reported in 7 patients (12.5%) with the 3.5 mg/kg dose. Only mild and transient treatment-related AEs were observed. Injection site pain or discomfort decreased with time on treatment, with only 4 subjects (7.1%) reporting pain or discomfort between 12-18 months. Safety profiles were similar pre- and post-dose increase. Anti-drug antibodies were detected but had no significant effect on PK, PD, safety or efficacy.

Conclusions

Transitioning patients to the Phase 3 somavaratan dose (3.5 mg/kg twice-monthly) at the start of the 2nd year of treatment led to an increase in mean peak IGF-I SDS, with similar safety profiles pre- and post-dose increase. After 18 months of continuous exposure to somavaratan and at least 6 months at the Phase 3 dose, the anticipated decline in 2nd-year HV was not observed.

Claims

WHAT IS CLAIMED IS:

1. A method of treating human pediatric growth hormone deficiency (PGHD) in a pediatric patient, the treatment comprising administering to the pediatric patient with PGHD a human growth hormone-XTEN (hGH-XTEN) fusion protein comprising an amino acid sequence having at least about 90% sequence identity to SEQ ID NO: 1 when optimally aligned, as a bodyweight adjusted bolus dose between about 0.80 mg/kg and about 6.3 mg/kg effective to increase the height of said pediatric patient, wherein the treatment continues for at least about 3 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

2. The method of claim 1, wherein the treatment continues for at least about 6 months from first administration.

3. The method of claim 1, wherein the treatment continues for at least about 12 months from first administration.

4. The method of claim 1, wherein the treatment continues for at least about 18 months from first administration.

5. The method of any one of claims 1 to 4, wherein the bolus dose of the hGH-XTEN fusion protein is administered once a month, two-times a month, three-times a month, or four-times a month.

6. The method of claim 5, wherein the bolus dose of the hGH-XTEN fusion protein is administered once a month.

7. The method of claim 5, wherein the bolus dose of the hGH-XTEN fusion protein is administered every two weeks or semimonthly.

8. The method of any one of claims 1 to 7, wherein the bolus dose of the hGH-XTEN fusion protein is administered subcutaneously.

9. The method of any one of claims 1 to 8, wherein the treatment is effective to maintain the pediatric patient's height velocity within at least about 10%, at least about 20%, or at least about 30%) of that compared to the height velocity achieved in pediatric patients administered daily injections of human growth hormone (hGH) alone of an equivalent amount, on a molar basis, over a comparable dose period.

10. The method of any one of claims 1 to 8, wherein the treatment is effective to achieve a height velocity equivalent to at least about 7 cm/yr to 12 cm/yr in a pediatric patient.

11. The method of any one of claims 1 to 8, wherein the treatment is effective to achieve a height velocity equivalent to at least about 8 cm/yr to 11 cm/yr in a pediatric patient.

12. The method of claims 10 or 11, wherein the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient.

13. The method of claims 10 or 11, wherein the height velocity achieved is a first year height velocity.

14. The method of any one of claims 1 to 8, wherein the treatment is effective to achieve at least the same height velocity as that achieved by administering daily injections of hGH alone over the same time period.

15. The method of claim 14, wherein the amount of hGH-XTEN fusion protein administered is comparable, on a molar basis, to an equivalent amount of an hGH alone and administered to a pediatric patient.

16. The method of any one of claims 10 to 15, wherein the bolus dose of the hGH-XTEN fusion protein is selected from about 0.8 mg/kg to about 1.5 mg/kg, about 1.8 mg/kg to about

3.2 mg/kg, or about 3.5 mg/kg to about 6.3 mg/kg.

17. The method of any one of claims 1 to 16, wherein the pediatric patient maintains an increase from baseline serum IGF-I standard deviation score (SDS) of at least 1.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, at least about 30 days, or at least about one month following administration of the hGH-XTEN fusion protein.

18. The method of any one of claims 1 to 16, wherein the pediatric patient maintains an increase from baseline serum IGF-I standard deviation score (SDS) of at least 1.0 for at least about 14 days, at least about 21 days, or at least about 30 days following administration of the hGH-XTEN fusion protein.

19. The method of any one of claims 1 to 16, wherein the pediatric patient maintains an increase from baseline serum IGF-I standard deviation score (SDS) of at least 1.0 for at least about 14 days, or at least about 30 days following administration of the hGH-XTEN fusion protein.

20. The method of any one of claims 1 to 16, wherein the pediatric patient has a serum IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 following

administration of the hGH-XTEN fusion protein.

21. The method of claim 20, wherein the IGF-I SDS is selected from the group consisting of greater than about -1.5 to about 2.0, greater than about -1.0 to about 2.0, greater than about -0.5 to about 2.0, greater than about 0 to about 2.0, greater than about 0.5 to about 2.0, greater than about 1.0 to about 2.0, and greater than about 1.5 to about 2.0.

22. The method of claim 20, wherein the IGF-I SDS is selected from the group consisting of greater than about -1.0 to about 2.0, greater than about 0 to about 2.0, and greater than about 1.0 to about 2.0.

23. The method of claim 20, wherein the pediatric patient exhibits said serum IGF-I SDS following administration of the bolus dose, wherein the administration of the hGH-XTEN fusion protein is once a month, two-times a month, three-times a month, or four-times a month.

24. The method of claim 20, wherein the pediatric patient exhibits said serum IGF-I SDS following administration of the bolus dose, wherein the administration of the hGH-XTEN fusion protein is two-times a month, or once a month.

25. The method of any one of claims 17 to 24, wherein the pediatric patient exhibits said serum IGF-I SDS following administration of at least a second, or a third, or a fourth bolus dose of the hGH-XTEN fusion protein.

26. The method of claim 20, wherein the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, at least about 30 days, or at least about one month following administration of the hGH-XTEN fusion protein.

27. The method of claim 26, wherein the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 14 days, at least about 21 days, or at least about 30 days following administration of the hGH-XTEN fusion protein.

28. The method of claim 26, wherein the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 14 days, or at least about 30 days following administration of the hGH-XTEN fusion protein.

29. The method of any one of claims 26 to 28, wherein the IGF-I SDS is maintained between about -2.0 and about 2.0 following administration of a first, or a second, or a third, or a fourth bolus dose of the hGH-XTEN fusion protein.

30. The method of any one of claims 1 to 29, wherein the bolus dose of the hGH-XTEN fusion protein is selected from the group consisting of about 0.8 mg/kg, about 1.0 mg/kg, about 1.2 mg/kg, about 1.4 mg/kg, about 1.6 mg/kg, about 1.8 mg/kg, about 2.0 mg/kg, about 2.2 mg/kg, about 2.4 mg/kg, about 2.6 mg/kg, about 2.7 mg/kg, about 2.8 mg/kg, about 3 mg/kg, about 3.2 mg/kg, about 3.4 mg/kg, about 3.6 mg/kg, about 3.8 mg/kg, about 4.0 mg/kg, about 4.2 mg/kg, about 4.4 mg/kg, about 4.6 mg/kg, about 4.8 mg/kg, about 5.0 mg/kg, about 5.2 mg/kg, about 5.4 mg/kg, about 5.6 mg/kg, about 5.8 mg/kg, about 6.0 mg/kg, and about 6.3 mg/kg.

31. The method of any one of claims 1 to 29, wherein the bolus dose of the hGH-XTEN fusion protein is about 0.8 mg/kg to about 1.5 mg/kg.

32. The method of any one of claims 1 to 29, wherein the bolus dose of the hGH-XTEN fusion protein is about 1.8 mg/kg to about 3.2 mg/kg.

33. The method of any one of claims 1 to 29, wherein the bolus dose of the hGH-XTEN fusion protein is about 3.5 mg/kg to about 6.3 mg/kg.

34. The method of any one of claims 1 to 33, wherein the hGH-XTEN fusion protein comprises the amino acid sequence of SEQ ID NO: 1.

35. The method of any one of claims 1 to 33, wherein the hGH-XTEN fusion protein has at least about 91%, or at least about 92%, or at least about 93%, or at least about 94%, or at least about 95%, or at least about 96%, or at least about 97%, or at least about 98%, or at least about 99% sequence identity to the amino acid sequence of SEQ ID NO: 1 when optimally aligned.

36. A method of treating human pediatric growth hormone deficiency (PGHD) in a human pediatric patient, comprising administering to the patient with PGHD a human growth hormone-XTEN (hGH-XTEN) fusion protein comprising an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1 as a therapeutically effective bodyweight adjusted bolus dose that is effective to maintain the patient's serum IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 for at least 7 days after administration of the bolus dose, wherein the treatment continues for at least about 3 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

37. The method of claims 36, wherein the treatment continues at least about 6 months, at least about 12 months, or at least about 18 months from the first administration of the hGH- XTEN fusion protein.

38. The method of claims 36, wherein the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient.

39. The method of claim 36, wherein the bolus dose of the hGH-XTEN fusion protein is between about 0.8 mg/kg and about 6.3 mg/kg.

40. The method of claim 36 or 37, wherein said bolus dose is effective to maintain the patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 7 days, at least about 8 days, at least about 9 days, at least about 10 days, at least about 11 days, at least about 12 days, at least about 13 days, at least about 14 days, at least about 15 days, at least about 16 days, at least about 17 days, at least about 18 days, at least about 19 days, at least about 20 days, at least about 21 days, at least about 22 days, at least about 23 days, at least about 24 days, at least about 25 days, at least about 26 days, at least about 27 days, at least about 28 days, at least about 29 days, at least about 30 days, or at least about one month following administration.

41. The method of claim 40, wherein the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 14 days, at least about 21 days, or at least about 30 days following administration of the hGH-XTEN fusion protein.

42. The method of claim 40, wherein the bolus dose is effective to maintain the pediatric patient's serum IGF-I SDS between about -2.0 and about 2.0 for at least about 14 days, or at least about 30 days following administration of the hGH-XTEN fusion protein.

43. A pediatric bolus dose of an hGH-XTEN fusion protein comprising an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1, wherein the bolus dose is a therapeutically effective bodyweight adjusted bolus dose comprising between about 0.8 mg/kg and about 6.3 mg/kg of hGH-XTEN fusion protein.

44. The bolus dose of claim 43 for use in treating human pediatric growth hormone deficiency (PGHD) in a pediatric patient in need, wherein the treatment continues for at least about 3 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

45. The bolus dose of claims 44, wherein the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH-XTEN fusion protein.

46. The bolus dose of claims 44, wherein the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient.

47. The bolus dose of claims 43 or 44, wherein the hGH-XTEN fusion protein comprises the amino acid sequence of SEQ ID NO: 1.

48. The bolus dose of any one of claims 43 to 47, which is formulated for subcutaneous administration.

49. An hGH-XTEN fusion protein comprising an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1 for use in a method for the treatment of human pediatric growth hormone deficiency (PGHD) in a human pediatric patient, wherein the method comprises administering a bodyweight adjusted bolus dose of the hGH-XTEN fusion protein at a dose between about 0.8 mg/kg and about 6.3 mg/kg effective to increase the height of said pediatric patient, wherein the treatment continues for at least about 3 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

50. The fusion protein of any claim 49, wherein the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH-XTEN fusion protein.

51. The fusion protein of claims 49, wherein the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing of the hGH-XTEN fusion protein in the pediatric patient.

52. Use of an hGH-XTEN fusion protein comprising an amino acid sequence having at least about 90% sequence identity to the amino acid sequence of SEQ ID NO: 1 in the manufacture of a medicament for the treatment of PGHD in a pediatric patient, wherein the hGH-XTEN fusion protein is administered to the pediatric patient as a bodyweight adjusted bolus dose of the hGH-XTEN fusion protein at a dose between about 0.8 mg/kg and about 6.3 mg/kg effective to increase the height of said pediatric patient, wherein the treatment continues for at least about 3 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

53. The use of claim 52, wherein the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH- XTEN fusion protein.

54. The use of claim 52, wherein the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient.

55. The hGH-XTEN fusion protein of claim 49 or the use of any one of claims 52 to 54, wherein the bolus dose is administered once a month, two-times a month, three-times a month, or four-times a month.

56. The hGH-XTEN fusion protein of claim 49 or the use of any one of claims 52 to 54, wherein the bolus dose is administered semimonthly, or monthly.

57. The hGH-XTEN fusion protein of claim 49 or the use of claim 52, wherein the hGH- XTEN fusion protein comprises the amino acid sequence of SEQ ID NO: 1.

58. The hGH-XTEN fusion protein of claim or the use of claim 52, wherein the bolus dose is administered subcutaneously.

59. The hGH-XTEN fusion protein of claim 49 or the use of claim 52, wherein the human pediatric patient has a serum IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 following administration of the bolus dose.

60. The hGH-XTEN fusion protein of claims 49 or the use of claim 59, wherein the IGF-I SDS is selected from the group consisting of greater than about -1.5, greater than about -1.0, greater than about -0.5, greater than about 0, greater than about 0.5, greater than about 1.0, and greater than about 1.5.

61. The hGH-XTEN fusion protein of claim 49 or the use of claim 59, wherein the IGF-I SDS is selected from the group consisting of greater than about -1.0, greater than about 0, and greater than ab out 1.0.

62. The hGH-XTEN fusion protein of any claim 49 or the use of claim 52, wherein the administration is once a month, two-times a month, three-times a month, or four-times a month.

63. The hGH-XTEN fusion protein of 49 or the use of claim 52, wherein the

administration is once a month, or two-times a month.

64. A kit for the treatment of pediatric growth hormone deficiency (PGHD) comprising (i) a container which holds a pharmaceutical composition comprising a human growth hormone-XTEN (hGH-XTEN) fusion protein comprising an amino acid sequence having at least about 90% sequence identity to SEQ ID NO: 1 when optimally aligned, and

(ii) a package insert associated with said container, wherein the package insert indicates that said composition is for the treatment of pediatric growth hormone deficiency (PGHD) in a pediatric patient by administration of an initial dose of the hGH-XTEN fusion protein between about 0.8 mg/kg and about 6.3 mg/kg effective to increase the height of said pediatric patient, wherein the treatment continues for at least about 3 months from first administration, and a plurality of subsequent doses of the hGH-XTEN fusion protein between about 0.8 mg/kg and about 6.3 mg/kg, wherein the doses are administered once a month, two- times a month, three-times a month, or four-times a month, and wherein the pediatric patient's height velocity does not decline during the treatment.

65. The kit of claims 64, wherein the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH- XTEN fusion protein.

66. The kit of claims 64, wherein the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient.

67. The kit of claim 64, wherein the container further comprises a pharmaceutically acceptable carrier.

68. A human growth hormone-XTEN (hGH-XTEN) fusion protein comprising an amino acid sequence having at least about 90% sequence identity to SEQ ID NO: 1 when optimally aligned for use in a pharmaceutical regimen for treatment of a pediatric growth hormone deficiency (PGHD) in a pediatric patient, said regimen comprising administering a bolus dose of the hGH-XTEN fusion protein to treat the pediatric patient, wherein the treatment continues for at least about 3 months from first administration, and wherein the pediatric patient's height velocity does not decline during the treatment.

69. The fusion protein of claims 68, wherein the treatment continues for at least about 6 months, at least about 12 months, or at least about 18 months from first administration of the hGH-XTEN fusion protein.

70. The fusion protein of claims 68, wherein the height velocity is achieved after at least about 3 months, at least about 6 months, at least about 12 months, or at least about 18 months of dosing in the pediatric patient.

71. The hGH-XTEN fusion protein of any one of claims 68 to 70, wherein the

pharmaceutical regimen further comprises the step of determining the amount of hGH-XTEN fusion protein needed to achieve an IGF-I standard deviation score (SDS) between about -2.0 and about 2.0 in the pediatric patient.

72. The hGH-XTEN fusion protein of any one of claims 68 to 71, wherein the

pharmaceutical regimen for treating the pediatric patient comprises administering the hGH- XTEN fusion protein in an initial bolus dose between about 0.8 mg/kg and about 6.3 mg/kg and a plurality of subsequent bolus doses of the hGH-XTEN fusion protein between about 0.8 mg/kg and about 6.3 mg/kg.

73. The hGH-XTEN fusion protein of claim 72, wherein the bolus doses are administered once a month, two-times a month, three-times a month, or four-times a month.

74. The hGH-XTEN fusion protein of claim 72, wherein the bolus doses are administered once a month, or two-times a month.