The present invention relates to combinations, pharmaceutical compositions and fusion molecules comprising an FGF21 (fibroblast growth factor 21 ) compound and a GLP-1 R (glucagon-like peptide-1 receptor) agonist with optimized GLP-1 R agonist / FGF21 compound activity ratio. It further relates to their use as medicaments, in particular for the treatment of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and/or atherosclerosis.

Background of the Invention

Administration of fibroblast growth factor 21 (FGF21 ) compounds, e.g., recombinantly produced FGF21 polypeptides, results in substantial decrease in body weight, blood glucose and plasma lipids as well as in improved insulin sensitivity, as demonstrated, for example, by Gaich et al. (2013) Cell Metab 18(3): 333-340 and Dong et al. (2015) Br J Clin Pharmacol 80(5): 1051 -1063. Glucagon-like peptide-1 receptor (GLP-1 R) agonists provide effective glucose and body weight lowering in humans, as shown, for example, by Astrup et al. (2012) Int J Obes (Lond) 36(6): 843-854 and Nauck et al. (2013) Diabetes Obes Metab 15(3): 204-212. Combining the beneficial effects of FGF21 administration with the glucose-lowering effects of GLP-1 receptor agonists surprisingly resulted in synergistic effects (see, e.g., WO 201 1/089203 A1 and WO 2014/037373 A1 ) that provide a more comprehensive treatment of diseases/disorders, such as obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and/or atherosclerosis.

Summary of the Invention

A combination of an FGF21 compound and a GLP-1 R agonist, e.g., in the form of a fusion protein, can, for example, be used for improving glycemic control in overweight to obese dyslipidemic patients with type 2 diabetes mellitus.

Notably, FGF21 and GLP-1 (as the primary GLP-1 R agonist) exert their pharmacological effects at different plasma concentrations. More particularly, FGF21 effects kick in at higher plasma levels as compared to GLP-1 effects. In addition, at higher levels, GLP-1 is known to have adverse effects, e.g., nausea and vomiting. Taken together, this implies a potential risk of GLP-1 -mediated adverse effects when administering a combination of an FGF21 compound and a GLP-1 R agonist, e.g., in the form of a fusion protein.

Accordingly, it was an object of the present invention to determine the optimal GLP-1 R agonist / FGF21 compound activity ratio in order to achieve the beneficial effects while avoiding potential adverse effects (e.g., nausea and vomiting). It was a further object of the present invention to provide corresponding combinations, pharmaceutical compositions and fusion molecules with optimized GLP-1 R agonist / FGF21 compound activity ratio.

In one aspect, the present invention relates to a combination comprising an FGF21 (fibroblast growth factor 21 ) compound and a GLP-1 R (glucagon-like peptide-1 receptor) agonist, wherein the FGF21 compound has an FGF21 activity which is the same or substantially the same as the FGF21 activity of native FGF21 , and

wherein the GLP-1 R agonist has a GLP-1 R agonistic activity which is 9- to 531 -fold (or 9.449- to 531 .0-fold) reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the FGF21 activity refers to activation of the FGF21 receptor. In one embodiment, the term refers to the activity in vitro. In one embodiment, activation of the FGF21 receptor is determined by measuring FGF21 receptor autophosphorylation upon contact with the FGF21 compound in vitro. In one embodiment, FGF21 activity is determined by using an In-Cell Western (ICW) assay, e.g., essentially as described in Example 3.

In one embodiment, the GLP-1 R agonistic activity refers to activation of the GLP-1 receptor. In one embodiment, the term refers to the agonistic activity in vitro. In one embodiment, activation of the GLP-1 receptor is determined by measuring the cAMP response of cells stably expressing GLP-1 receptor upon contact with the agonist in vitro. In one embodiment, activation of the GLP-1 receptor is determined essentially as described in Example 4.

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is 9- to 482-fold (or 9.449- to 482.396-fold) or 9- to 319-fold (or 9.449- to 319.31 1 -fold) or 9- to 121 -fold (or 9.449-to 121 .189-fold) reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is 9- to 319-fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is at least 9.4-fold or at least 9.45-fold or at least 9.5-fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is at least 10-fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is at most 482.4-fold or at most 482.35-fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is at most 482-fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is 10- to 482-reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is 10- to 319-reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is 90- to 100-fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is at least 18-fold (or at least 18.268-fold) reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is 18- to 501 -fold (or 18.268- to 500.686-fold) or 18- to 469-fold (or 18.268- to 468.679-fold) or 18- to 313-fold (or 18.268- to 313.214-fold) or 18- to 123-fold (or 18.268- to 123.466-fold) reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist has a GLP-1 R agonistic activity which is 18- to 313-fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one of the above embodiments, the GLP-1 R agonist has a GLP-1 R agonistic activity which is at least 18.2-fold or at least 18.3-fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the FGF21 compound is native FGF21 or an FGF21 variant having at least 80% or at least 90% or at least 95% amino acid sequence identity to the amino acid sequence of native FGF21 .

In one embodiment, the GLP-1 R agonist comprises or consists of the amino acid sequence

H-G-E-G-T-F-T-S-D-X10-S-X12-Q-X14-X15-E-E-X18-V-X20-X21-F-I-E-W-L-X27-X28-X29-X30 (SEQ ID

NO: 37),

wherein

wherein, optionally, the amino acid sequence comprises at least one additional amino acid residue at its N-terminus; and

wherein, optionally, the amino acid sequence comprises a peptide extension consisting of up to 12, 1 1 or 10 amino acid residues at its C-terminus.

In one embodiment, the GLP-1 R agonist comprises or consists of an amino acid sequence selected from the group consisting of SEQ ID NOs: 9, 10, 12, 14, 15, 16, 17, 19 and 20.

In another aspect, the present invention relates to a pharmaceutical composition comprising an FGF21 (fibroblast growth factor 21 ) compound and a GLP-1 R (glucagon-like peptide-1 receptor) agonist together with a pharmaceutically acceptable carrier and/or excipient,

wherein the FGF21 compound has an FGF21 activity which is the same or substantially the same as the FGF21 activity of native FGF21 , and

wherein the GLP-1 R agonist has a GLP-1 R agonistic activity which is 9- to 531 -fold (or 9.449- to 531 .0-fold) reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist and/or the FGF21 compound are as defined above.

In yet another aspect, the present invention relates to a fusion molecule comprising an FGF21 (fibroblast growth factor 21 ) compound and a GLP-1 R (glucagon-like peptide-1 receptor) agonist, wherein the FGF21 compound has an FGF21 activity which is the same or substantially the same as the FGF21 activity of native FGF21 , and

wherein the GLP-1 R agonist has a GLP-1 R agonistic activity which is 9- to 531 -fold (or 9.449- to 531 .0-fold) reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist and/or the FGF21 compound are as defined above.

In another aspect, the present invention relates to a nucleic acid molecule encoding a fusion molecule as defined above.

In another aspect, the present invention relates to a host cell containing a nucleic acid molecule as defined above.

In another aspect, the present invention relates to a kit comprising a combination as defined above, a pharmaceutical composition as defined above, a fusion molecule as defined above, a nucleic acid molecule as defined above or a host cell as defined above.

In another aspect, the present invention relates to a combination as defined above, a pharmaceutical composition as defined above, a fusion molecule as defined above, a nucleic acid molecule as defined above or a host cell as defined above for use as a medicament.

In another aspect, the present invention relates to a combination as defined above, a pharmaceutical composition as defined above, a fusion molecule as defined above, a nucleic acid molecule as defined above or a host cell as defined above for use in the treatment of a disease or disorder selected from the group consisting of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and atherosclerosis.

In one embodiment, the disease or disorder is diabetes mellitus. In one embodiment, the diabetes mellitus is type 1 diabetes mellitus or type 2 diabetes mellitus.

In another aspect, the present invention relates to the use of a combination as defined above, a pharmaceutical composition as defined above, a fusion molecule as defined above, a nucleic acid molecule as defined above or a host cell as defined above in the manufacture of a medicament for the treatment of a disease or disorder selected from the group consisting of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and atherosclerosis.

In one embodiment, the disease or disorder is diabetes mellitus. In one embodiment, the diabetes mellitus is type 1 diabetes mellitus or type 2 diabetes mellitus.

In another aspect, the present invention relates to a method of treating a disease or disorder selected from the group consisting of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and atherosclerosis, the method comprising administering a combination as defined above, a pharmaceutical composition as defined above, a fusion molecule as defined above, a nucleic acid molecule as defined above or a host cell as defined above to a subject in need thereof.

In one embodiment, the disease or disorder is diabetes mellitus. In one embodiment, the diabetes mellitus is type 1 diabetes mellitus or type 2 diabetes mellitus.

In another aspect, the present invention relates to a GLP-1 R agonist having a GLP-1 R agonistic activity which is 9- to 531 -fold (or 9.449- to 531 .0-fold) reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

In one embodiment, the GLP-1 R agonist is as defined above.

In one embodiment, the GLP-1 R agonist comprises or consists of the amino acid sequence

H-G-E-G-T-F-T-S-D-Xi o-S-Xi2-Q-Xi4-Xi5-E-E-Xi8-V-X2o-X2i-F-l-E-W-L-X27-X28-X29-X3o (SEQ ID

NO: 37),

wherein

X28 is A, N or K;

X3o is G or R;

wherein, optionally, the amino acid sequence comprises at least one additional amino acid residue at its N-terminus; and

wherein, optionally, the amino acid sequence comprises a peptide extension consisting of up to 12, 1 1 or 10 amino acid residues at its C-terminus.

In one embodiment, the GLP-1 R agonist comprises or consists of an amino acid sequence selected from the group consisting of SEQ ID NOs: 9, 10, 12, 14, 15, 16, 17, 19 and 20.

In another aspect, the present invention relates to a nucleic acid molecule encoding a GLP-1 R agonist as defined above.

In another aspect, the present invention relates to a host cell containing a nucleic acid molecule as defined above.

In another aspect, the present invention relates to a pharmaceutical composition or kit comprising a GLP-1 R agonist as defined above, a nucleic acid molecule as defined above or a host cell as defined above.

In another aspect, the present invention relates to a GLP-1 R agonist as defined above, a pharmaceutical composition as defined above, a nucleic acid molecule as defined above or a host cell as defined above for use as a medicament.

In another aspect, the present invention relates to a GLP-1 R agonist as defined above, a pharmaceutical composition as defined above, a nucleic acid molecule as defined above or a host cell as defined above for use in the treatment of a disease or disorder selected from the group consisting of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and atherosclerosis.

In one embodiment, the disease or disorder is diabetes mellitus. In one embodiment, the diabetes mellitus is type 1 diabetes mellitus or type 2 diabetes mellitus.

In another aspect, the present invention relates to the use of a GLP-1 R agonist as defined above, a pharmaceutical composition as defined above, a nucleic acid molecule as defined above or a host cell as defined above in the manufacture of a medicament for the treatment of a disease or disorder selected from the group consisting of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and atherosclerosis.

In one embodiment, the disease or disorder is diabetes mellitus. In one embodiment, the diabetes mellitus is type 1 diabetes mellitus or type 2 diabetes mellitus.

In another aspect, the present invention relates to a method of treating a disease or disorder selected from the group consisting of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and atherosclerosis, the method comprising administering a GLP-1 R agonist as defined above, a pharmaceutical composition as defined above, a nucleic acid molecule as defined above or a host cell as defined above to a subject in need thereof.

In one embodiment, the disease or disorder is diabetes mellitus. In one embodiment, the diabetes mellitus is type 1 diabetes mellitus or type 2 diabetes mellitus.

Description of the Figures

Figure 1 is a graph showing EC50 of the adverse effect (gastric emptying (GE) rate) and pharmacodynamics (i.e., HbA1 c, Triglycerides, Fatty Acids, Non-HDL, Adipose Mass) depending on the GLP-1 attenuation factor (12-months simulation):

• For GLP-1 attenuation factors greater than 9.449 (can be rounded to 9), EC50 of GLP-1 - mediated gastrointestinal adverse effect (gastric emptying; GE-Rate) was greater than EC50 of pharmacodynamic effects (i.e., HbA1 c, Adipose Mass, Non-HDL, Fatty Acids, Triglycerides);

• Maximal distance between maximum of pharmacodynamics (HbA1 c) and adverse effect (GE-Rate) normalized by spreading of FGF21 - (lipids) and GLP-1 -mediated effects (HbA1 c) was 121 .189; i.e. at 121 .189 (can be rounded to 121 ), there is a maximal distance between maximum of pharmacodynamics effects (HbA1 c) and adverse effect (GE-Rate) at a minimum distance between GLP-1 -mediated effects (HbA1 c) and mean FGF21 - mediated effects (i.e., Adipose Mass, Non-HDL, Fatty Acids, Triglycerides) (see Figure 2);

• Maximal distance between maximum of pharmacodynamics (HbA1 c) and adverse effect (GE-Rate) was 319.31 1 (can be rounded to 319);

• Maximal distance between mean pharmacodynamics (i.e., HbA1 c, Adipose Mass, Non- HDL, Fatty Acids, Triglycerides) and adverse effect (GE-Rate) was 482.396 (see Figure

2; can be rounded to 482);

• Maximum of gastric emptying rate at 531 .0;

(all: vertical lines).

Figure 2 is a graph showing EC50 of gastric emptying (GE) rate and mean pharmacodynamic effects (i.e., HbAl c, Triglycerides, Fatty Acids, Non-HDL, Adipose Mass) depending on GLP-1 attenuation factor (12-months simulation):

• Maximal distance between mean pharmacodynamics (i.e., HbAl c, Adipose Mass, Non- HDL, Fatty Acids, Triglycerides) and adverse effect (GE-Rate) was 482.396 (right vertical line; can be rounded to 482);

• Maximal distance between maximum of pharmacodynamics (HbAl c) and adverse effect (GE-Rate) normalized by spreading of FGF21 - (lipids) and GLP-1 -mediated effects

(HbAl c) was 121 .189 (left vertical line; can be rounded to 121 ). The curve "(Max-GE Rate)/Range" represents the ratio between the maximum distance between HbAl c and GE-Rate and the minimum distance between HbAl c and mean FGF21 -mediated effects (i.e., Adipose Mass, Non-HDL, Fatty Acids, Triglycerides). At the minimum of the "(Max- GE Rate)/Range" curve (i.e. at 121 .189), there is a maximal distance between maximum of pharmacodynamics effects (HbAl c) and adverse effect (GE-Rate) at a minimum distance between GLP-1 -mediated effects (HbAl c) and FGF21 -mediated effects (i.e., Adipose Mass, Non-HDL, Fatty Acids, Triglycerides).

Figure 3 is a graph showing EC50 of the adverse effect (gastric emptying (GE) rate) and pharmacodynamics (HbAl c, Triglycerides, Fatty Acids, Non-HDL, Adipose Mass) depending on GLP-1 attenuation factor (3-months simulation):

• For GLP-1 attenuation factors greater than 18.268 (can be rounded to 18), EC50 of GLP- 1 -mediated gastrointestinal adverse effect (gastric emptying; GE-Rate) was greater than EC50 of pharmacodynamic effects (i.e., HbAl c, Adipose Mass, Non-HDL, Fatty Acids,

Triglycerides);

• Maximal distance between maximum of pharmacodynamics (HbAl c) and adverse effect (GE-Rate) normalized by spreading of FGF21 - (lipids) and GLP-1 -mediated effects (HbA1 c) was 123.466; i.e. at 123.466 (can be rounded to 123), there is a maximal distance between maximum of pharmacodynamics effects (HbAl c) and adverse effect (GE-Rate) at a minimum distance between GLP-1 -mediated effects (HbAl c) and mean FGF21 - mediated effects (i.e., Adipose Mass, Non-HDL, Fatty Acids, Triglycerides) (see Figure 4);

• Maximal distance between maximum of pharmacodynamics (HbAl c) and adverse effect (GE-Rate) was 313.214 (can be rounded to 313);

• Maximal distance between mean pharmacodynamics (i.e., HbA1 c, Adipose Mass, Non- HDL, Fatty Acids, Triglycerides) and adverse effect (GE-Rate) was 468.679 (see Figure 4; can be rounded to 469);

• Maximum of gastric emptying rate at 500.686 (can be rounded to 501 )

(all: vertical lines).

Figure 4 is a graph showing EC50 of gastric emptying (GE) rate and mean pharmacodynamic effects (i.e., HbA1 c, Triglycerides, Fatty Acids, Non-HDL, Adipose Mass) depending on GLP-1 attenuation factor (3-months simulation):

· Maximal distance between mean pharmacodynamics (i.e. HbA1 c, Adipose Mass, Non- HDL, Fatty Acids, Triglycerides) and adverse effect (GE-Rate) was 468.679 (right vertical line; can be rounded to 469);

• Maximal distance between maximum of pharmacodynamics (HbA1 c) and adverse effect (GE-Rate) normalized by spreading of FGF21 - (lipids) and GLP-1 -mediated effects (HbA1 c) was 123.466 (left vertical line; can be rounded to 123). The curve "(Max-GE

Rate)/Range" represents the ratio between the maximum distance between HbA1 c and GE-Rate and the minimum distance between HbA1 c and mean FGF21 -mediated effects (i.e., Adipose Mass, Non-HDL, Fatty Acids, Triglycerides). At the minimum of the "(Max- GE Rate)/Range" curve (i.e. at 123.466), there is a maximal distance between maximum of pharmacodynamics effects (HbA1 c) and adverse effect (GE-Rate) at a minimum distance between GLP-1 -mediated effects (HbA1 c) and FGF21 -mediated effects (i.e., Adipose Mass, Non-HDL, Fatty Acids, Triglycerides).

Figure 5 shows dose-response curves of (A) FGFR autophosphorylation or (B) ERK1 /2-phosphorylation in CHO cells overexpressing human FGFRI c and beta-klotho after stimulus with mature human FGF21 (SEQ ID NO: 2) measured via In-Cell Western.

Detailed Description of the Invention

Although the present invention is described in detail below, it is to be understood that this invention is not limited to the particular methodologies, protocols and reagents described herein as these may vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to limit the scope of the present invention which will be limited only by the appended claims. Unless defined otherwise, all technical and scientific terms used herein have the same meanings as commonly understood by one of ordinary skill in the art.

In the following, certain elements of the present invention will be described. These elements may be listed with specific embodiments, however, it should be understood that they may be combined in any manner and in any number to create additional embodiments. The variously described examples and preferred embodiments should not be construed to limit the present invention to only the explicitly described embodiments. This description should be understood to support and encompass embodiments which combine the explicitly described embodiments with any number of the disclosed and/or preferred elements. Furthermore, any permutations and combinations of all described elements in this application should be considered disclosed by the description of the present application unless the context indicates otherwise.

The terms used herein are defined as described in "A multilingual glossary of biotechnological terms: (lUPAC Recommendations)", H.G.W. Leuenberger, B. Nagel, and H. Kolbl, Eds., Helvetica Chimica Acta, CH-4010 Basel, Switzerland, (1995).

The practice of the present invention will employ, unless otherwise indicated, conventional methods of chemistry, biochemistry, cell biology, immunology, and recombinant DNA techniques which are explained in the literature in the field (Sambrook, J. et al. (2001 ) Molecular Cloning: A Laboratory Manual, 3rd Ed., Cold Spring Harbor Laboratory Press, Cold Spring Harbor, NY).

Throughout this specification and the claims which follow, unless the context requires otherwise, the word "comprise", and variations such as "comprises" and "comprising", will be understood to imply the inclusion of a stated member, integer or step or group of members, integers or steps but not the exclusion of any other member, integer or step or group of members, integers or steps although in some embodiments such other member, integer or step or group of members, integers or steps may be excluded, i.e. the subject-matter consists in the inclusion of a stated member, integer or step or group of members, integers or steps. The terms "a" and "an" and "the" and similar reference used in the context of describing the invention (especially in the context of the claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. Recitation of ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range. Unless otherwise indicated herein, each individual value is incorporated into the specification as if it were individually recited herein. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g., "such as"), provided herein is intended merely to better illustrate the invention and does not pose a limitation on the scope of the invention otherwise claimed. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the invention.

Several documents are cited throughout the text of this specification. Each of the documents cited herein (including all patents, patent applications, scientific publications, manufacturer's specifications, instructions, etc.), whether supra or infra, are hereby incorporated by reference in their entirety. Nothing herein is to be construed as an admission that the invention is not entitled to antedate such disclosure by virtue of prior invention.

By using a systems pharmacology approach that integrated key components of GLP-1 receptor signaling and FGF21 production and action in the context of diabetic pathophysiology, the inventors succeeded in determining the optimal GLP-1 R agonist / FGF21 compound activity ratio in order to achieve the beneficial effects of both active agents (e.g., in terms of body weight, lipids, glycemic control) while avoiding potential adverse effects (e.g., nausea and vomiting).

The term "combination", as used herein, is meant to include means that allow to apply the combination comprising the FGF21 compound and the GLP-1 R agonist either by separate administration of the FGF21 compound and the GLP-1 R agonist to the patient or in the form of combination products in which the FGF21 compound and the GLP-1 R agonist are present, e.g., in one pharmaceutical composition or in the form of a fusion molecule/protein. When administered separately, administration may occur simultaneously or sequentially, in any order. The amount of the FGF21 compound and the GLP-1 R agonist as well as the relative timings of administration will be selected in order to achieve the desired combined therapeutic effect. The administration of the combination may be concomitantly in: (1 ) a unitary pharmaceutical composition including all active pharmaceutical ingredients; or (2) separate pharmaceutical compositions each including at least one of the active pharmaceutical ingredients. Alternatively, the combination may be administered separately in a sequential manner wherein one treatment agent is administered first and the other second or vice versa. Such sequential administration may be close in time or remote in time. In one embodiment, the combination is provided in the form of a kit, e.g., a kit as defined herein.

The term "fibroblast growth factor 21 " or "FGF21 ", as used herein, refers to any FGF21 protein known in the art and particularly refers to human FGF21 . In one embodiment, human FGF21 has the amino acid sequence of SEQ ID NO: 1 .

The term "FGF21 compound", as used herein, generally refers to a compound having FGF21 activity.

In one embodiment, the FGF21 compound is a peptidic compound, i.e., a peptide or protein.

The term "peptide", as used herein, refers to a polymeric form of amino acids of any length, for example, comprising two or more, or 3 or more, or 4 or more, or 6 or more, or 8 or more, or 9 or more, or 10 or more, or 13 or more, or 16 or more, or 21 or more amino acids joined covalently by peptide bonds. A peptide may, for example, consist of up to 100 amino acids. The term "polypeptide" refers to large peptides, preferably to peptides with more than 100 amino acid residues. The terms "polypeptide" and "protein" are used interchangeably herein.

In one embodiment, the FGF21 compound is native FGF21 or an FGF21 variant having at least 80% or at least 90% or at least 91 % or at least 92% or at least 93% or at least 94% or at least 95% or at least 96% or at least 97% or at least 98% amino acid sequence identity to the amino acid sequence of native FGF21 .

The term "native FGF21 ", as used herein, refers to a naturally occurring FGF21 , e.g., human wild-type FGF21 with the amino acid sequence of SEQ ID NO: 1 (also referred to as "full-length human wild-type FGF21 "). The term "native FGF21 ", as used herein, also includes mature FGF21 , i.e., a naturally occurring FGF21 lacking the natural signal sequence (also referred to as signal peptide). In one embodiment, the native FGF21 is mature human wild-type FGF21 lacking amino acids 1 to 28 (M1 to A28) of SEQ ID NO: 1 , and is represented by SEQ ID NO: 2.

"Sequence identity" between two amino acid sequences indicates the percentage of amino acids that are identical between the sequences. The optimal alignment of the sequences for comparison may be produced, besides manually, by means of the local homology algorithm of Smith and Waterman, 1981 , Ads App. Math. 2, 482, by means of the local homology algorithm of Neddleman and Wunsch, 1970, J. Mol. Biol. 48, 443, by means of the similarity search method of Pearson and Lipman, 1988, Proc. Natl Acad. Sci. USA 85, 2444, or by means of computer programs which use these algorithms (GAP, BESTFIT, FASTA, BLAST P, BLAST N and T FAST A in Wisconsin Genetics Software Package, Genetics Computer Group, 575 Science Drive, Madison, Wis.).

An FGF21 variant may be based on the deletion, addition and/or substitution of at least one amino acid residue in/to the native FGF21 (e.g., of SEQ ID NO: 1 or 2).

Such deletion, addition and/or substitution may contribute to an increased stability, e.g., proteolytic and/or thermal stability, of the variant as compared to the native FGF21 (e.g., SEQ ID NO: 1 or 2). This may be achieved, for example, by the prevention of protease cleavage at or in proximity to the substituted amino acid or by formation of one or more additional disulfide bridges.

The term "amino acid" or "amino acid residue", as used herein, refers to naturally occurring amino acids, unnatural amino acids, amino acid analogues and amino acid mimetics that function in a

manner similar to the naturally occurring amino acids, all in their D and L stereoisomers if their structure allows such stereoisomeric forms. Amino acids are referred to herein by either their name, their commonly known three letter symbols or by the one-letter symbols recommended by the lUPAC-IUB Biochemical Nomenclature Commission.

When used in connection with amino acids, the term "naturally occurring" refers to the 20 conventional amino acids (i.e., alanine (A), cysteine (C), aspartic acid (D), glutamic acid (E), phenylalanine (F), glycine (G), histidine (H), isoleucine (I), lysine (K), leucine (L), methionine (M), asparagine (N), proline (P), glutamine (Q), arginine (R), serine (S), threonine (T), valine (V), tryptophan (W), and tyrosine (Y)), as well as selenocysteine, pyrrolysine (PYL), and pyrroline-carboxylysine (PCL).

The term "unnatural amino acid", as used herein, is meant to refer to amino acids that are not naturally encoded or found in the genetic code of any organism. They may, for example, be purely synthetic compounds. Examples of unnatural amino acids include, but are not limited to, hydroxyproline, gamma-carboxyglutamate, O-phosphoserine, azetidinecarboxylic acid, 2-aminoadipic acid, 3-aminoadipic acid, beta-alanine, aminopropionic acid, 2-aminobutyric acid, 4-aminobutyric acid, 6-aminocaproic acid, 2-aminoheptanoic acid, 2-aminoisobutyric acid, 3-aminoisobutyric acid, 2-aminopimelic acid, tertiary-butylglycine, 2,4-diaminoisobutyric acid, desmosine, 2,2'-diaminopimelic acid, 2,3-diaminoproprionic acid, N-ethylglycine, N-methylglycine, N-ethylasparagine, homoproline, hydroxylysine, allo-hydroxylysine, 3-hydroxyproline, 4-hydroxyproline, isodesmosine, allo-isoleucine, N-methylalanine, N-methylglycine, N-methylisoleucine, N-methylpentylglycine, N-methylvaline, naphthalanine, norvaline, norleucine, ornithine, D-ornithine, D-arginine, p-aminophenylalanine, pentylglycine, pipecolic acid and thioproline.

The term "amino acid analogue", as used herein, refers to compounds that have the same basic chemical structure as a naturally occurring amino acid. Amino acid analogues include the natural and unnatural amino acids which are chemically blocked, reversibly or irreversibly, or their C-terminal carboxy group, their N-terminal amino group and/or their side-chain functional groups are chemically modified. Such analogues include, but are not limited to, methionine sulfoxide, methionine sulfone, S-(carboxymethyl)-cysteine, S-(carboxymethyl)-cysteine sulfoxide, S-(carboxymethyl)-cysteine sulfone, aspartic acid-(betamethylester), N-ethylglycine, alanine carboxamide, homoserine, norleucine and methionine methyl sulfonium.

The term "amino acid mimetics", as used herein, refers to chemical compounds that have a structure that is different from the general chemical structure of an amino acid, but function in a manner similar to a naturally occurring amino acid.

In some embodiments, the variant comprises at least one additional amino acid at its N-terminus. In one embodiment, the at least one additional amino acid is selected from naturally occurring amino acids except proline, unnatural amino acids, amino acid analogues and amino acid mimetics. In one embodiment, the at least one additional amino acid is selected from the group consisting of G, A, N and C. In a particular embodiment, the at least one additional amino acid is G.

Suitable FGF21 variants for use in the present invention are described, e.g., in PCT/EP2016/079551 , which is incorporated herein by reference.

In one embodiment, the FGF21 compound is an FGF21 variant comprising or consisting of an amino acid sequence selected from the group consisting of SEQ ID NOs: 3, 4, 5 and 6.

The FGF21 compound comprised in the combinations, pharmaceutical compositions and fusion molecules of the invention exhibits FGF21 activity which is the same or substantially the same as the FGF21 activity of native FGF21 (e.g., SEQ ID NO: 2). In one embodiment, the FGF21 activity refers to the FGF21 activity of the FGF21 compound when it is not comprised in (is not a component of) a fusion molecule as defined herein and/or when it is not further modified (see below).

The term "substantially the same", as used herein, refers to an FGF21 activity which is in the range of 50 to 150% or 60 to 140% or 65 to 135% of the FGF21 activity of native FGF21 (e.g., SEQ ID NO: 2).

In one embodiment, the term "FGF21 activity" (or "FGF21 potency"), as used herein, refers to activation of the FGF21 receptor (FGFR, e.g., FGFRI c). In one embodiment, the FGF21 receptor is a human FGF21 receptor. In one embodiment, the term refers to the activity/potency in vitro. In another embodiment, the term refers to the activity/potency in vivo. In one embodiment, activation of the FGF21 receptor is determined by measuring FGF21 receptor autophosphorylation upon contact with the FGF21 compound in vitro. In one embodiment, FGF21 activity/potency is determined by using an In-Cell Western (ICW) assay. In one embodiment, the activity/potency is quantified by determining the EC50 value.

The term "In-Cell Western (ICW) assay", as used herein, refers to an immunocytochemical assay, more particularly a quantitative immunofluorescence assay, usually performed in microplates (e.g., in a 96- or 384-well format). It combines the specificity of Western blotting with the reproducibility and throughput of ELISA (see, for example, Aguilar H.N. et al. (2010) PLoS ONE 5(4): e9965). Appropriate ICW assay systems are commercially available (e.g., from LI-COR Biosciences, USA). In one embodiment, an anti-pFGFR and/or and anti-pERK is/are used in the ICW assay. In one embodiment, a pFGFR ICW assay is performed. In one embodiment, the ICW assay is performed essentially as described in Example 3.

In one embodiment, the FGF21 compound having an FGF21 activity which is the same or substantially the same as the FGF21 activity of native FGF21 may be defined in terms of its EC50 value of FGF21 receptor activation. For example, an FGF21 compound having an FGF21 activity in the range of 50 to 150% or 60 to 140% or 65 to 135% of the FGF21 activity of native FGF21 (e.g., SEQ ID NO: 2) may also be referred to herein as an FGF21 compound which activates the FGF21 receptor with an EC50 of 2.40 to 7.20 nmol/L or 2.88 to 6.72 nmol/L or 3.12 to 6.48 nmol/L, respectively, in a pFGFR ICW assay, e.g., as essentially described in Example 3. In one embodiment, the EC50 value is given as EC50±SD. In one embodiment, SD is the assay-dependent standard deviation. In one embodiment, the EC50 is 2.40±SD to 7.20±SD nmol/L or 2.88±SD to 6.72±SD nmol/L or 3.12±SD to 6.48±SD nmol/L, respectively, in a pFGFR ICW assay, e.g., as essentially described in Example 3. In one embodiment, SD is 1 .8 nmol/L.

In accordance with the present invention, the FGF21 compound may be further modified, e.g., fused/conjugated to another entity/molecule, such as a polymer (e.g., PEG) or a peptide/polypeptide, such as human serum albumin (HSA) or an Fc region/domain of an immunoglobulin or a variant thereof, e.g., as described further below. In one embodiment, the FGF21 activity of the FGF21 compound referred to herein is the FGF21 activity of the FGF21 compound without such further modification, also referred to herein as "pure FGF21 compound".

The term "fused to", as used herein, refers, in particular, to genetic fusion, e.g., by recombinant DNA technology. The amino acid sequence of a (poly)peptide half-life extension module may be introduced at any position within the amino acid sequence of the variant, and may, for example, take the shape of a loop within the encoded protein structure, or it may be N-terminally or C-terminally fused.

The term "conjugated to", as used herein, refers, in particular, to chemical and/or enzymatic conjugation resulting in a stable covalent link between a (poly-)peptide and another molecule, e.g., the variant and the half-life extension module. Such conjugation may occur at the N- or C-terminus or at particular side chains of a (poly-)peptide, e.g., at lysine, cysteine, tyrosine or unnatural amino acid residues.

The term "GLP-1 R agonist" (in short: "GLP-1 RA"), as used herein, generally refers to a compound which binds to and activates the GLP-1 receptor, such as GLP-1 (as the primary GLP-1 R agonist).

In one embodiment, the GLP-1 R agonist is a peptidic compound, i.e., a peptide or protein. In another embodiment, the GLP-1 R agonist is a small molecule, i.e., an organic compound with a molecular weight of less than 900 Da.

The GLP-1 R agonist comprised in the combinations, pharmaceutical compositions and fusion molecules of the invention exhibits a GLP-1 R agonistic activity which is reduced as compared to that of native GLP-1 (7-36) as defined herein. Value "x" in the expression "x-fold reduced", as used herein, may be referred to herein as "attenuation factor" or "reduction factor". In one embodiment, the GLP-1 R agonistic activity which is reduced as compared to that of native GLP-1 (7-36) as defined herein is exhibited when the GLP-1 R agonist is a component of a fusion molecule as defined herein.

The term "native GLP-1 (7-36)", as used herein, refers to a peptide having the amino acid sequence of SEQ ID NO: 7, which, optionally, comprises an amide group at its C-terminus.

In one embodiment, the term "GLP-1 R agonistic activity" (or "GLP-1 R agonistic potency"), as used herein, refers to the activation of the GLP-1 receptor. In one embodiment, the term refers to the agonistic activity/potency in vitro. In another embodiment, the term refers to the agonistic activity/potency in vivo. In one embodiment, activation of the GLP-1 receptor is determined by measuring the cAMP response of cells stably expressing GLP-1 receptor upon contact with the agonist in vitro. In one embodiment, the cells are from a HEK-293 cell line. In one embodiment, the GLP-1 receptor is human GLP-1 receptor. In one embodiment, activation of the GLP-1 receptor is determined essentially as described in Example 4. In one embodiment, the activity/potency is quantified by determining the EC50 value.

In one embodiment, the GLP-1 R agonist having a GLP-1 R agonistic activity which is reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36) may be defined in terms of its EC50 value of GLP-1 receptor activation, e.g., as indicated in Table 4. For example, a GLP-1 R agonist having a GLP-1 R agonistic activity which is 9- to 531 -fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36) may also be referred to herein as a GLP-1 R agonist which activates the GLP-1 receptor with an EC50 of 6.93 to 408.87 pmol/L, etc. In one embodiment, the EC50 value is determined as described above. In one embodiment, the EC50 value is given as EC50±SD. In one embodiment, SD is the assay-dependent standard deviation.

Suitable GLP-1 R agonists having a GLP-1 R agonistic activity which is reduced as compared to that of native GLP-1 (7-36) can be identified by the assays described herein for determining GLP-1 R agonistic activity, e.g., an assay as described in Example 4 or in Xiao et al. (2001 ) Biochemistry. 40(9): 2860-9 or Gault et al. (2013) J Biol Chem. 288(49): 35581 -91 , e.g., analysis of GLP-1 R agonist-induced production of cytosolic cAMP, β-cell preserving action (apoptosis), or glucose-stimulated insulin secretion (GSIS) etc. They can be identified, for example, by producing variants of known peptidic GLP-1 R agonists, such as native GLP-1 (7-36), e.g., by random or site-directed mutagenesis or chemical synthesis (see, e.g., Example 5), and subsequent determination of their GLP-1 R agonistic activity as described herein using native GLP-1 (7-36) as control. Alternatively, they can be identified by screening of small molecule libraries in terms of GLP-1 R agonistic activity using native GLP-1 (7-36) as control. All of these assays can be performed in the form of high-throughput assays.

A variant of a known peptidic GLP-1 R agonist (e.g., native GLP-1 (7-36)) may be based on the deletion, addition and/or substitution of at least one amino acid residue in/to the amino acid sequence of the known peptidic GLP-1 R agonist.

In one embodiment, the variant comprises up to 15, 14, 13, 12, 1 1 , 10, 9, 8, 7, 6 or 5 substitutions of amino acid residues.

In one embodiment, the GLP-1 R agonist is a variant of native GLP-1 (7-36) comprising up to 15, 14, 13, 12, 1 1 , 10, 9, 8, 7, 6 or 5 substitutions of amino acid residues in the sequence of native GLP-1 (7-36). In one embodiment, the substitutions are selected from the group comprising or consisting of A8G, V16L, V16K, S18K, S18I, Y19Q, L20M, E21 D, G22E, Q23E, A24R, A25V, K26R, K26Q, E27L, A30E, V33K, V33L, V33E, K34N, K34A, G35T and R36G and/or substitutions as listed in Table 5 (see description of SEQ ID NOs: 8 to 20).

In some embodiments, the variant comprises at least one additional amino acid residue at its N-terminus. In one embodiment, the at least one additional amino acid residue is selected from naturally occurring amino acids except proline, unnatural amino acids, amino acid analogues and amino acid mimetics. In one embodiment, the at least one additional amino acid residue is selected from the group consisting of G, A, N and C. In a particular embodiment, the at least one additional amino acid residue is (a single) G.

In some embodiments, the variant comprises a peptide extension at its C-terminus. The peptide extension may, for example, consist of up to 12, 1 1 or 10 amino acid residues. In one embodiment, the peptide extension has an amino acid sequence selected from the group consisting of PSSGAPPPS (SEQ ID NO: 38), PVSGAPPPS (SEQ ID NO: 39), PSSGEPPPES (SEQ ID NO:

40), PSSGEPPPE (SEQ ID NO: 41 ), PKKQRLS (SEQ ID NO: 42) and PKKIRYS (SEQ ID NO: 43).

In one embodiment, the GLP-1 R agonist having a GLP-1 R agonistic activity which is reduced as compared to that of native GLP-1 (7-36) as defined herein comprises or consists of the amino acid sequence

H-G-E-G-T-F-T-S-D-X10-S-X12-Q-X14-X15-E-E-X18-V-X20-X21-F-I-E-W-L-X27-X28-X29-X30 (SEQ ID

NO:37),

wherein

X10 is any amino acid, e.g. L or K;

X12 is any amino acid, e.g. K or I;

Xl4 is any amino acid, e.g. L or M;

Xl5 is any amino acid, e.g. E or D;

Xl8 is any amino acid, e.g. A or R;

X20 is any amino acid, e.g. R or Q;

X21 is any amino acid, e.g. L or E;

X27 is any amino acid, e.g. L, E, K or V;

X28 is any amino acid, e.g. A, N or K;

X29 is any amino acid, e.g. T or G;

X30 is any amino acid, e.g. G or R;

wherein, optionally, the amino acid sequence comprises at least one additional amino acid residue at its N-terminus; and

wherein, optionally, the amino acid sequence comprises a peptide extension consisting of up to 12, 1 1 or 10 amino acid residues at its C-terminus.

In one embodiment, X27 is L, E or V, e.g., L. In one embodiment, X28 is A or K, e.g., A.

In one embodiment, the at least one additional amino acid residue is selected from the group consisting of G, A, N and C. In a particular embodiment, the at least one additional amino acid residue is (a single) G.

In one embodiment, the peptide extension has an amino acid sequence selected from the group consisting of PSSGAPPPS (SEQ ID NO: 38), PVSGAPPPS (SEQ ID NO: 39), PSSGEPPPES (SEQ ID NO: 40), PSSGEPPPE (SEQ ID NO: 41 ), PKKQRLS (SEQ ID NO: 42) and PKKIRYS (SEQ ID NO: 43).

Modifications as disclosed herein, such as introduction of G at the N-terminus or Xi2 = I, lead to suitable reduction of GLP-1 R agonistic activity.

In one embodiment, the GLP-1 R agonist having a GLP-1 R agonistic activity which is reduced as compared to that of native GLP-1 (7-36) as defined herein comprises or consists of an amino acid sequence selected from the group consisting of SEQ ID NOs: 9, 10, 12, 14, 15, 16, 17, 19 and 20.

In accordance with the present invention, the GLP-1 R agonist may be further modified, e.g. as described above in connection with the FGF21 compound.

A pharmaceutical composition in accordance with the present invention comprises one or more carriers and/or excipients, all of which are pharmaceutically acceptable. The term "pharmaceutically acceptable", as used herein, refers to the non-toxicity of a material which, preferably, does not interact with the action of the active agent of the pharmaceutical composition.

The term "carrier" refers to an organic or inorganic component, of a natural or synthetic nature, in which the active component is combined in order to facilitate, enhance or enable application. According to the invention, the term "carrier" also includes one or more compatible solid or liquid fillers, diluents or encapsulating substances, which are suitable for administration to a subject.

Claims

A combination comprising an FGF21 (fibroblast growth factor 21 ) compound and a GLP-1 R (glucagon-like peptide-1 receptor) agonist,

wherein the FGF21 compound has an FGF21 activity which is the same or substantially the same as the FGF21 activity of native FGF21 , and

wherein the GLP-1 R agonist has a GLP-1 R agonistic activity which is 9- to 531 -fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

2. The combination according to claim 1 , wherein the GLP-1 R agonist has a GLP-1 R agonistic activity which is 9- to 482-fold or 9- to 319-fold or 9- to 121 -fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

3. The combination according to claim 1 , wherein the GLP-1 R agonist has a GLP-1 R agonistic activity which is 18- to 501 -fold or 18- to 469-fold or 18- to 313-fold or 18- to 123-fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

4. The combination according to any of claims 1 to 3, wherein the FGF21 compound is native FGF21 or an FGF21 variant having at least 80% or at least 90% or at least 95% amino acid sequence identity to the amino acid sequence of native FGF21 .

5. The combination according to any of claims 1 to 4, wherein the GLP-1 R agonist comprises or consists of the amino acid sequence

H-G-E-G-T-F-T-S-D-X10-S-X12-Q-X14-X15-E-E-X18-V-X20-X21-F-I-E-W-L-X27-X28-X29-X30 (SEQ ID

NO: 37),

wherein

X27 is L, E, K or V;

X28 is A, N or K;

X3o is G or R;

wherein, optionally, the amino acid sequence comprises at least one additional amino acid residue at its N-terminus; and

wherein, optionally, the amino acid sequence comprises a peptide extension consisting of up to 12, 1 1 or 10 amino acid residues at its C-terminus.

6. The combination according to any of claims 1 to 5, wherein the GLP-1 R agonist comprises or consists of an amino acid sequence selected from the group consisting of SEQ ID NOs: 9, 10,

12, 14, 15, 16, 17, 19 and 20.

7. A pharmaceutical composition comprising an FGF21 (fibroblast growth factor 21 ) compound and a GLP-1 R (glucagon-like peptide-1 receptor) agonist together with a pharmaceutically acceptable carrier and/or excipient,

wherein the FGF21 compound has an FGF21 activity which is the same or substantially the same as the FGF21 activity of native FGF21 , and

wherein the GLP-1 R agonist has a GLP-1 R agonistic activity which is 9- to 531 -fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

8. A fusion molecule comprising an FGF21 (fibroblast growth factor 21 ) compound and a GLP-1 R (glucagon-like peptide-1 receptor) agonist,

wherein the FGF21 compound has an FGF21 activity which is the same or substantially the same as the FGF21 activity of native FGF21 , and

wherein the GLP-1 R agonist has a GLP-1 R agonistic activity which is 9- to 531 -fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

9. The pharmaceutical composition according to claim 7 or the fusion molecule according to claim 8, wherein the GLP-1 R agonist and/or the FGF21 compound are as defined in any of claims 2 to 6.

10. A nucleic acid molecule encoding a fusion molecule according to claim 8 or 9.

1 1 . A host cell containing a nucleic acid molecule according to claim 10.

12. A kit comprising a combination according to any of claims 1 to 6, a pharmaceutical composition according to claim 7 or 9, a fusion molecule according to claim 8 or 9, a nucleic acid molecule according to claim 10 or a host cell according to claim 1 1 .

13. A combination according to any of claims 1 to 6, a pharmaceutical composition according to claim 7 or 9, a fusion molecule according to claim 8 or 9, a nucleic acid molecule according to claim 10 or a host cell according to claim 1 1 for use as a medicament.

14. A combination according to any of claims 1 to 6, a pharmaceutical composition according to claim 7 or 9, a fusion molecule according to claim 8 or 9, a nucleic acid molecule according to claim 10 or a host cell according to claim 1 1 for use in the treatment of a disease or disorder selected from the group consisting of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and atherosclerosis.

15. Use of a combination according to any of claims 1 to 6, a pharmaceutical composition according to claim 7 or 9, a fusion molecule according to claim 8 or 9, a nucleic acid molecule according to claim 10 or a host cell according to claim 1 1 in the manufacture of a medicament for the treatment of a disease or disorder selected from the group consisting of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and atherosclerosis.

16. A method of treating a disease or disorder selected from the group consisting of obesity, being overweight, metabolic syndrome, diabetes mellitus, diabetic retinopathy, hyperglycemia, dyslipidemia, Non-Alcoholic SteatoHepatitis (NASH) and atherosclerosis, the method comprising administering a combination according to any of claims 1 to 6, a pharmaceutical composition according to claim 7 or 9, a fusion molecule according to claim 8 or 9, a nucleic acid molecule according to claim 10 or a host cell according to claim 1 1 to a subject in need thereof.

17. The combination, pharmaceutical composition, fusion molecule, nucleic acid molecule or host cell for use according to claim 14, the use of claim 15 or the method of claim 16, wherein the diabetes mellitus is type 1 diabetes mellitus or type 2 diabetes mellitus.

18. A GLP-1 R agonist having a GLP-1 R agonistic activity which is 9- to 531 -fold reduced as compared to the GLP-1 R agonistic activity of native GLP-1 (7-36).

19. The GLP-1 R agonist according to claim 18 comprising or consisting of the amino acid sequence

H-G-E-G-T-F-T-S-D-Xio-S-Xi2-Q-Xi4-Xi5-E-E-Xi8-V-X2o-X2i-F-l-E-W-L-X27-X28-X29-X3o (SEQ ID

NO:37),

wherein

wherein, optionally, the amino acid sequence comprises at least one additional amino acid residue at its N-terminus; and

wherein, optionally, the amino acid sequence comprises a peptide extension consisting of up to 12, 1 1 or 10 amino acid residues at its C-terminus.

20. The GLP-1 R agonist according to claim 18 or 19 comprising or consisting of an amino acid sequence selected from the group consisting of SEQ ID NOs: 9, 10, 12, 14, 15, 16, 17, 19 and 20.