U.S. patent application number 15/101258 was filed with the patent office on 2016-10-20 for novel combination treatment for acute myeloid leukemia (aml).
The applicant listed for this patent is HOFFMANN-LA ROCHE INC.. Invention is credited to Brian Higgins, Gwen Nichols, Kathryn E. Packman.
Application Number | 20160303158 15/101258 |
Document ID | / |
Family ID | 52014047 |
Filed Date | 2016-10-20 |
United States Patent
Application |
20160303158 |
Kind Code |
A1 |
Higgins; Brian ; et
al. |
October 20, 2016 |
NOVEL COMBINATION TREATMENT FOR ACUTE MYELOID LEUKEMIA (AML)
Abstract
The present invention relates to a pharmaceutical product
comprising a) as a first component an inhibitor of the MDM2-p53
interaction; and b) as a second component cytarabine; as a combined
preparation for the sequential or simultaneous use in the treatment
of cancer, particularly AML.
Inventors: |
Higgins; Brian; (Fresh
Meadows, NY) ; Packman; Kathryn E.; (Newton, MA)
; Nichols; Gwen; (New York, NY) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
HOFFMANN-LA ROCHE INC. |
Nutley |
NJ |
US |
|
|
Family ID: |
52014047 |
Appl. No.: |
15/101258 |
Filed: |
December 1, 2014 |
PCT Filed: |
December 1, 2014 |
PCT NO: |
PCT/EP2014/076063 |
371 Date: |
June 2, 2016 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
61912152 |
Dec 5, 2013 |
|
|
|
Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 31/7068 20130101;
A61P 35/02 20180101; A61K 9/0019 20130101; A61K 31/40 20130101;
A61P 43/00 20180101; A61K 31/77 20130101; A61P 35/00 20180101; A61K
45/06 20130101; A61K 31/77 20130101; A61K 2300/00 20130101; A61K
31/40 20130101; A61K 2300/00 20130101; A61K 31/7068 20130101; A61K
2300/00 20130101 |
International
Class: |
A61K 31/7068 20060101
A61K031/7068; A61K 9/00 20060101 A61K009/00; A61K 31/40 20060101
A61K031/40 |
Claims
1. A pharmaceutical product comprising a) as a first component an
inhibitor of the MDM2-p53 interaction; and b) as a second component
cytarabine; as a combined preparation for the sequential or
simultaneous use in the treatment of cancer.
2. The pharmaceutical product according to claim 1, wherein the
inhibitor of the MDM2-p53 interaction is selected from a compound
of formula (I) ##STR00004## wherein n is from 3 to 70.
3. The pharmaceutical product according to claim 2, wherein n is
from 30 to 60.
4. The pharmaceutical product according to claim 2, wherein n is
from 40 to 50.
5. The pharmaceutical product according to claim 2, wherein n is
41, 42, 43, 44, 46, 47, 48 or 49.
6. The pharmaceutical product according to claim 1, wherein the
inhibitor of the MDM2-p53 interaction is
4-{[(2R,3S,4R,5S)-3-(3-Chloro-2-fluoro-phenyl)-4-(4-chloro-2-fluoro-pheny-
l)-4-cyano-5-(2,2-dimethyl-propyl)-pyrrolidine-2-carbonyl]-amino}-3-methox-
y-benzoic acid 1-mPEG-carbonyloxy-ethyl ester (mPEG, average MW,
.about.2000).
7. The pharmaceutical product according to claim 1, wherein the
inhibitor of the MDM2-p53 interaction is
4-{[(2R,3S,4R,5S)-3-(3-Chloro-2-fluoro-phenyl)-4-(4-chloro-2-fluoro-pheny-
l)-4-cyano-5-(2,2-dimethyl-propyl)-pyrrolidine-2-carbonyl]-amino}-3-methox-
y-benzoic acid 1-mPEG-carbonyloxy-ethyl ester (mPEG, average MW,
.about.2200).
8. The pharmaceutical product according to claim 1 for the
treatment of Acute Myeloid Leukemia (AML).
9. The pharmaceutical product according to claim 1 for the
treatment of solid tumors.
10. A method for the treatment of cancer, comprising administering
to a patient in need of such treatment an effective amount of a
pharmaceutical product according to claim 1.
11. The method according to claim 10, wherein the cancer is Acute
Myeloid Leukemia (AML).
12. The method according to claim 10, wherein the cancer is a solid
tumor.
13. (canceled)
14. A pharmaceutical product comprising, a) as a first component a
compound of formula (I) according to claim 2; and b) as a second
component the compound cytarabine, wherein both components are
administered intravenously, as a combined preparation for the
simultaneous or sequential use in the treatment of cancer;
characterized in that the dose of the compound of formula (I)
corresponds to a dose of compound (A) ##STR00005## within the range
from about 200 to about 1600 mg/day.
15. The pharmaceutical product according to claim 14, wherein the
compound of formula (I) is the compound
4-{[(2R,3S,4R,5S)-3-(3-Chloro-2-fluoro-phenyl)-4-(4-chloro-2-fluoro-pheny-
l)-4-cyano-5-(2,2-dimethyl-propyl)-pyrrolidine-2-carbonyl]-amino}-3-methox-
y-benzoic acid 1-mPEG-carbonyloxy-ethyl ester (mPEG, average MW,
.about.2000).
16. The pharmaceutical product according to claim 14, wherein the
compound of formula (I) is the compound
4-{[(2R,3S,4R,5S)-3-(3-Chloro-2-fluoro-phenyl)-4-(4-chloro-2-fluoro-pheny-
l)-4-cyano-5-(2,2-dimethyl-propyl)-pyrrolidine-2-carbonyl]-amino}-3-methox-
y-benzoic acid 1-mPEG-carbonyloxy-ethyl ester (mPEG, average MW,
.about.2200).
17. The pharmaceutical product according to claim 14, wherein the
compound of formula (I) is administered on days 1 to 5, followed by
a 23 days rest period of a 28 days treatment cycle.
18. The pharmaceutical product according to claim 17, wherein the
compound of formula (I) is administered once daily (qd) or two
times a day (BID).
19. The pharmaceutical product according to claim 14, wherein the
cancer is Acute Myeloid Leukemia (AML).
20. (canceled)
Description
[0001] The present invention relates to a combination therapy for
the treatment of proliferative disorders such as cancer, in
particular Acute Myeloid Leukemia (AML). More particularly, the
present invention discloses combinations of the current backbone
therapy in AML, the compound cytarabine (Ara-C), together with a
compound which acts as an inhibitor of the MDM2-p53 interaction. It
was surprisingly found that such combinations show a more than
additive (synergistic) effect.
[0002] p53 is a tumor suppressor protein that plays a central role
in protection against development of cancer. It guards cellular
integrity and prevents the propagation of permanently damaged
clones of cells by the induction of growth arrest or apoptosis. At
the molecular level, p53 is a transcription factor that can
activate a panel of genes implicated in the regulation of cell
cycle and apoptosis. p53 is a potent cell cycle inhibitor which is
tightly regulated by MDM2 at the cellular level. MDM2 and p53 form
a feedback control loop. MDM2 can bind p53 and inhibit its ability
to transactivate p53-regulated genes. In addition, MDM2 mediates
the ubiquitin-dependent degradation of p53. p53 can activate the
expression of the MDM2 gene, thus raising the cellular level of
MDM2 protein. This feedback control loop insures that both MDM2 and
p53 are kept at a low level in normal proliferating cells. MDM2 is
also a cofactor for E2F, which plays a central role in cell cycle
regulation.
[0003] The ratio of MDM2 to p53 is dysregulated in many cancers.
Frequently occurring molecular defects in the p16INK4/p19ARF locus,
for instance, have been shown to affect MDM2 protein degradation.
Inhibition of MDM2-p53 interaction in tumor cells with functional
p53 should lead to accumulation of p53, cell cycle arrest and/or
apoptosis. MDM2 antagonists, therefore, can offer a novel approach
to cancer therapy as single agents or in combination with a broad
spectrum of other antitumor therapies. The feasibility of this
strategy has been shown by the use of different macromolecular
tools for inhibition of MDM2-p53 interaction (e.g. antibodies,
antisense oligonucleotides, peptides). MDM2 also binds E2F through
a conserved binding region as p53 and activates E2F-dependent
transcription of cyclin A, suggesting that MDM2 antagonists might
have effects in p53 mutant cells with functional p53 signaling.
[0004] Inhibitors of the MDM2-p53 interaction have been shown to
induce apoptosis in the established human AML cell line MOLM-13,
which overexpresses MDM2 (K. Kojima, et. al., Blood 2005,
106(9):3150-9). It has now been found that the combination of
compounds of formula (I) together with Ara-C provide more than
additive effects in disseminated MOLM-13 AML model in
immunocompromised mice. Compounds of formula (I) and their
preparation are disclosed in WO2013/135648. These compounds act as
pro drugs of the compound
##STR00001##
[0005]
4-{[(2R,3S,4R,5S)-4-(4-Chloro-2-fluoro-phenyl)-3-(3-chloro-2-fluoro-
-phenyl)-4-cyano-5-(2,2-dimethyl-propyl)-pyrrolidine-2-carbonyl]-amino}-3--
methoxy-benzoic acid (herein compound A).
[0006] Compound A is for example disclosed in U.S. Pat. No.
8,354,444 and WO2011/098398.
SUMMARY OF THE INVENTION
[0007] The present invention relates to a pharmaceutical product
comprising a) as a first component an inhibitor of the MDM2-p53
interaction (also "MDM2 inhibitor"); and b) as a second component
cytarabine; as a combined preparation for the sequential or
simultaneous use in the treatment of cancer.
[0008] The present invention further relates to a method of
treating a patient suffering from cancer, comprising administering
to the patient the combination as mentioned above.
[0009] The present invention also relates to a kit comprising a) a
first component which comprises, as an active agent, an inhibitor
of the MDM2-p53 interaction; and b) a second component which
comprises, as an active agent, the compound cytarabine.
[0010] In addition, the present invention relates to the use of an
MDM2 inhibitor and cytarabine for the treatment of cancer.
[0011] A yet further aspect of the present invention is the use of
an MDM2 inhibitor, and cytarabine for the preparation of a
medicament for the treatment of cancer.
[0012] In one embodiment, the inhibitor of the MDM2-p53 interaction
is selected from a compound of formula (I)
##STR00002##
whereby the compounds of formula (I) are further specified
herein.
BRIEF DESCRIPTION OF THE DRAWINGS
[0013] FIG. 1 illustrates the antitumor efficacy of the compound
I-B in combination with cytarabine on MOLM-13-luc.c4 (AML) tumor
burden in SCID-beige mice, by quantification of
bioluminescence.
DETAILED DESCRIPTION OF THE INVENTION
[0014] Compounds of formula (I), and in particular I-A and I-B as
disclosed herein, are polyethylene glycol (PEG) prodrugs of
compound (A) that were synthesized to provide the solubility
required for an intravenous (iv) formulation of the active parent
molecule compound (A). An iv formulation is desirable to ameliorate
dose-limiting gastrointestinal intolerability and exposure
variability, as well as to provide an acceptable route of
administration for treatment of hematological malignancies and for
pediatric use.
[0015] The anti-tumor activity of once weekly iv administration of
compound I-B and oral (po) compound (A) were compared as
monotherapies and in combination with the AML standard of care,
cytarabine (Ara-C), in the MOLM-13 model. Both compounds I-B and
(A) elicited a significant increase in lifespan (ILS) as
monotherapies, with up to 37% ILS observed as compared to Vehicle
control animals. Despite the lack of monotherapy activity with
Ara-C, it did significantly prolong survival in combination with
compound I-B or (A), with maximum ILS of 54% or 68% observed,
respectively. The synergistic effect demonstrated by the present
data suggests that the combination of targeting MDM2-p53 with an
MDM2 inhibitor and inducing S-phase arrest with cytarabine (Ara-C)
may be an effective therapeutic strategy for the treatment of AML.
These data also demonstrate that the efficacy of compound (A) can
be maintained by the prodrug approach using the compounds of
formula (I), and in particular I-A and/or I-B.
[0016] Therefore, in one embodiment, the present invention relates
to a pharmaceutical product comprising a) as a first component an
inhibitor of the MDM2-p53 interaction; and b) as a second component
cytarabine; as a combined preparation for the sequential or
simultaneous use in the treatment of AML.
[0017] In another embodiment, the inhibitor of the MDM2-p53
interaction is selected from a compound of formula (I)
##STR00003##
wherein n is from 3 to 70.
[0018] In one embodiment, n is from 30 to 60.
[0019] In another embodiment, n is from 40 to 50.
[0020] In yet another embodiment, n is 41, 42, 43, 44, 46, 47, 48
or 49.
[0021] In another embodiment the compound of formula (I) is:
4-{[(2R,3S,4R,5S)-3-(3-Chloro-2-fluoro-phenyl)-4-(4-chloro-2-fluoro-pheny-
l)-4-cyano-5-(2,2-dimethyl-propyl)-pyrrolidine-2-carbonyl]-amino}-3-methox-
y-benzoic acid 1-mPEG-carbonyloxy-ethyl ester (mPEG, average MW,
.about.2000). This compound is designated herein as compound
I-A.
[0022] In another embodiment the compound of formula (I) is:
4-{[(2R,3S,4R,5S)-3-(3-Chloro-2-fluoro-phenyl)-4-(4-chloro-2-fluoro-pheny-
l)-4-cyano-5-(2,2-dimethyl-propyl)-pyrrolidine-2-carbonyl]-amino}-3-methox-
y-benzoic acid 1-mPEG-carbonyloxy-ethyl ester (mPEG, average MW,
.about.2200). This compound is designated herein as compound
I-B.
[0023] In yet another embodiment, the MDM2 inhibitor according to
the present invention may be the compound (A). Within this
embodiment, compound (A) is preferably provided as preparation for
peroral administration comprising an amorphous solid dispersion,
preferably a micro precipitated bulk powder (MBP), comprising
compound (A) and a polymer which stabilizes compound (A) in its
amorphous form, preferably HPMCAS. The peroral preparation is
reconstituted immediately before administration as a suspension in
Klucel/Tween. Compound (A) can be prepared according to methods for
example disclosed in U.S. Pat. No. 8,354,444 or WO2011/098398. Dose
selection in the current studies was based on previously determined
optimal doses for compound (A) in pre-clinical (animal) and
clinical (phase 1) trials.
[0024] The pharmaceutical products or methods according to the
present invention are particularly useful in the treatment or
control of hematological tumors, such as leukemias, and especially
for the treatment of Acute Myeloid Leukemia (AML). They may also be
useful in the treatment of other cell proliferative disorders
caused by disregulation of the MDM2-p53 interaction, such as
cancer, more particularly solid tumors such as, for example,
breast, colon, lung, melanoma, prostate, kidney, head and neck, or
sarcoma.
[0025] In one embodiment the present invention provides the present
pharmaceutical products and/or methods for the treatment of Acute
Myeloid Leukemia (AML).
[0026] In another embodiment the present invention provides the
present pharmaceutical products and/or methods for the treatment of
cell proliferative disorders caused by disregulation of the
MDM2-p53 interaction, such as cancer, more particularly solid
tumors such as, for example, breast, colon, lung, melanoma,
prostate, kidney, head and neck, or sarcoma.
[0027] Formulations of the compounds of formula (I) include those
suitable for oral, nasal and/or parenteral or intravenous
administration. The formulations may conveniently be presented in
unit dosage form and may be prepared by any methods well known in
the art of pharmacy.
[0028] In one embodiment, the compound of formula (I) is provided
in a stable lyophilized formulation for intravenous administration
comprising from about 0.1 mg to about 100 mg of compound (I), from
about 10 mM to about 100 mM of a buffering agent, from about 25 mg
to about 125 mg of a lyophilization bulking agent and an
isotonicity builder. The resultant formulation should have a pH of
about 5-7 via adjustment with HCl or NaOH.
[0029] In another embodiment, the compound of formula (I) is
dissolved in 0.9% sodium chloride in sterile water by vortexing,
then filtered thru a filter into a septum sealed vial for
intravenous administration.
[0030] The term "buffering agent" as used herein denotes a
pharmaceutically acceptable excipient, which stabilizes the pH of a
pharmaceutical preparation. Suitable buffers are well known in the
art and can be found in the literature. Preferred pharmaceutically
acceptable buffers comprise but are not limited to
histidine-buffers, citrate-buffers, succinate-buffers,
acetate-buffers and phosphate-buffers, especially, Succinic acid
(20-50 mM) and Phosphoric acid (10-50 mM). Most preferred buffers
comprise citrate, L-histidine or mixtures of L-histidine and
L-histidine hydrochloride. Other preferred buffer is acetate
buffer. Independently from the buffer used, the pH can be adjusted
with an acid or a base known in the art, e.g. hydrochloric acid,
acetic acid, phosphoric acid, sulfuric acid and citric acid, sodium
hydroxide and potassium hydroxide.
[0031] The preferred "bulking agent" is Trehalose dihydrate but
lactose, sucrose, sorbitol, glucose, raffinose, mannitol, dextran
and lower molecular weight amino acids such as glycine, valine and
arginine etc. and other bulking agents described in the scientific
literature may also be utilized.
[0032] As diluents for the formulated solution or reconstituted
solution from the lyophilized powder the following diluents such as
sodium chloride (0.9%), 5% Dextrose, water for injection, Lactated
Ringers solution or half normal saline may also be used. It is to
be appreciated that the bulking agent may also act as the
isotonicity building agent.
[0033] The amount of active ingredient which can be combined with a
carrier material to produce a single dosage form will vary
depending upon the host being treated, as well as the particular
mode of administration. The amount of active ingredient which can
be combined with a carrier material to produce a single dosage form
will generally be that amount of a formula I compound which
produces a therapeutic effect. Generally, out of one hundred
percent, this amount will range from about 1 percent to about
ninety-nine percent of active ingredient, preferably from about 5
percent to about 70 percent, most preferably from about 10 percent
to about 30 percent. A typical formulation is prepared by mixing a
compound of the present invention and a carrier or excipient.
Suitable carriers and excipients are well known to those skilled in
the art and are described in detail in, e.g., Ansel, Howard C., et
al., Ansel's Pharmaceutical Dosage Forms and Drug Delivery Systems.
Philadelphia: Lippincott, Williams & Wilkins, 2004; Gennaro,
Alfonso R., et al. Remington: The Science and Practice of Pharmacy.
Philadelphia: Lippincott, Williams & Wilkins, 2000; and Rowe,
Raymond C. Handbook of Pharmaceutical Excipients. Chicago,
Pharmaceutical Press, 2005.
[0034] Cytarabine was purchased from Hospira, Inc. Lake Forest,
Ill. 60045 USA, as sterile solution (100 mg/ml) for intravenous
(iv) injection.
[0035] The compounds of formula (I) as well as cytarabine are
administered in their therapeutically effective amount. More
particularly, the compounds of formula (I), especially of formula
I-A and I-B, are dosed in order to deliver a therapeutically active
amount of compound A to a patient. A therapeutically effective
amount of a compound in accordance with this invention means an
amount of compound that is effective to prevent, alleviate or
ameliorate symptoms of disease or prolong the survival of the
subject being treated. The determination of the amount of a pro
drug, for example a compound of formula (I), such as I-A or I-B, in
order to deliver a desired amount of active principal, for example
the compound A, to a patient is within routine work of a person of
ordinary skill in pharmaceutical sciences. In one embodiment of the
present invention the dose of prodrug of formula I-B of 437 mg/kg
is equivalent to 100 mg/kg of parent MDM2 inhibitor of compound
(A), due to 22.88% active compound loading in the prodrug.
[0036] The therapeutically effective amount or dosage of a compound
according to this invention can vary within wide limits and may be
determined in a manner known in the art. Such dosage will be
adjusted to the individual requirements in each particular case
including the specific compound(s) being administered, the route of
administration, the condition being treated, as well as the patient
being treated. In general, in the case of oral or parenteral
administration to adult humans weighing approximately 70 Kg, a
daily dosage of about 10 mg to about 3,000 mg, preferably from
about 80 mg to about 1600 mg of compound (A), should be
appropriate, although the upper limit may be exceeded when
indicated. The daily dosage can be administered as a single dose or
in divided doses, or for parenteral administration; it may be given
as continuous infusion.
[0037] In one embodiment, the present pharmaceutical products
comprise compounds of formula (I) characterized in that they are
dosed in such way as to deliver compound (A) in an amount of from
about 50 to about 3000 mg/day, or from about 80 to about 2500
mg/day, or from about 80 to about 1600 mg/day, or from about 200 to
about 1600 mg/day, or from about 400 to about 1600 mg/day, or from
about 400 to about 1200 mg/day, or from about 400 to about 1000
mg/day, or from about 400 to about 800 mg/day, or from about 400 to
about 600 mg/day for an administration period of up to about 7
days, preferably up to about 5 days, on days 1-7, or preferably
days 1-5, of a 28 day treatment cycle, followed by a rest period of
from about 21 to about 23 days, preferably up to about 23 days. The
daily dosage, i.e. the amount of compound (A) expressed in mg/day,
can be administered as a single dose (qd) or in two doses (BID).
When two doses are given, they are preferably administered in equal
amounts, once in the morning and once in the afternoon.
[0038] In another embodiment, the present pharmaceutical products
comprise compounds of formula (I), I-A or I-B, characterized in
that they are dosed in such way as to deliver compound A in an
amount of about 120 mg/day to about 1200 mg/day for an
administration period of up to 5 days, on days 1-5, of a 28 day
treatment cycle, followed by a rest period of 23 days. Doses are
administered as a single dose (qd) or in two doses (BID). Within
this embodiment, compound I-B is preferred.
[0039] In another embodiment, the present pharmaceutical products
comprise compounds of formula (I), I-A or I-B, characterized in
that they are dosed in such way as to deliver compound A in an
amount of from about 400 to about 1200 mg/day for an administration
period of up to 5 days, on days 1-5, of a 28 day treatment cycle,
followed by a rest period of 23 days. Doses are administered as a
single dose (qd) or in two doses (BID). Within this embodiment,
compound I-B is preferred.
[0040] In another embodiment, the present pharmaceutical products
comprise compounds of formula (I), I-A or I-B, characterized in
that they are dosed in such way as to deliver compound A in an
amount of from about 400 to about 800 mg/day for an administration
period of up to 5 days, on days 1-5, of a 28 day treatment cycle,
followed by a rest period of 23 days. Doses are administered as a
single dose (qd) or in two doses (BID). Within this embodiment,
compound I-B is preferred.
[0041] In another embodiment, the present pharmaceutical products
comprise compounds of formula (I), I-A or I-B, characterized in
that they are dosed in such way as to deliver compound A in an
amount of from about 400 to about 600 mg/day for an administration
period of up to 5 days, on days 1-5, of a 28 day treatment cycle,
followed by a rest period of 23 days. Doses are administered as a
single dose (qd) or in two doses (BID). Within this embodiment,
compound I-B is preferred.
[0042] In another embodiment, the present pharmaceutical products
comprise compounds of formula (I), I-A or I-B, characterized in
that they are dosed in such way as to deliver compound A in an
amount of about 120 mg/day to about 800 mg/day for an
administration period of up to 5 days, on days 1-5, of a 28 day
treatment cycle, followed by a rest period of 23 days. Doses are
administered as a single dose (qd) or in two doses (BID). Within
this embodiment, compound I-B is preferred.
[0043] In another embodiment, the present pharmaceutical products
comprise compounds of formula (I), I-A or I-B, characterized in
that they are dosed in such way as to deliver compound A in an
amount of about 120 mg/day to about 600 mg/day for an
administration period of up to 5 days, on days 1-5, of a 28 day
treatment cycle, followed by a rest period of 23 days. Doses are
administered as a single dose (qd) or in two doses (BID). Within
this embodiment, compound I-B is preferred.
[0044] In another embodiment, the present pharmaceutical products
comprise compounds of formula (I), I-A or I-B, characterized in
that they are dosed in such way as to deliver compound A in an
amount of about 120 mg/day to about 400 mg/day for an
administration period of up to 5 days, on days 1-5, of a 28 day
treatment cycle, followed by a rest period of 23 days. Doses are
administered as a single dose (qd) or in two doses (BID). Within
this embodiment, compound I-B is preferred.
[0045] In another embodiment, the present pharmaceutical products
comprise compounds of formula (I), I-A or I-B, characterized in
that they are dosed in such way as to deliver compound A in an
amount of about 120 mg/day for an administration period of up to 5
days, on days 1-5, of a 28 day treatment cycle, followed by a rest
period of 23 days. Doses are administered as a single dose (qd) or
in two doses (BID). Within this embodiment, compound I-B is
preferred.
[0046] A therapeutically effective amount (or "effective amount")
of cytarabine in accordance with this invention means an amount
effective to achieve the synergistic, i.e. more than additive
effect as demonstrated by the data disclosed herein (see e.g. FIG.
1). Since cytarabine is used as the backbone therapy for AML for
many years, a lot of information is available to the person of
skill in the art, for example a clinical physician, about effective
and tolerated doses in humans. It has for example been found that
cytarabine can be dosed as single agent in the treatment of AML
(induction regimen) in high amounts, such as amounts up to 3
g/m.sup.2 (intravenous) over 2 hours every 12 hours days 1 to 6. A
review about the use of cytarabine in the treatment of leukemias is
for example provided in "Nicholas D. Reese, Gary J. Schiller; Curr
Hematol Malig Rep, 2013, 8:141-148." In certain combination
therapies (e.g. induction therapy of acute non-lymphocytic
leukemia), the usual cytarabine dose in combination with other
anti-cancer drugs is 100 mg/m.sup.2/day by continuous iv infusion
(Days 1-7) or 100 mg/m.sup.2 iv every 12 hours (Days 1-7). (see for
example www.hospira.com).
[0047] Therefore, in one embodiment the present invention provides
a pharmaceutical product comprising, a) as an MDM2 inhibitor, a
compound of formula (I), I-A or I-B, wherein said compound is
administered intravenously (iv) once or two times per day on days 1
to 5, followed by a 23 days rest period, of a 28 days treatment
cycle; and b) as a second component an effective amount of the
compound cytarabine; as a combined preparation for the simultaneous
or sequential treatment of cancer, preferably AML. Within this
embodiment compounds I-A and I-B are preferred and are dosed in
such way as to deliver compound (A) in an amount of from about 50
to about 3000 mg/day, or from about 80 to about 2500 mg/day, or
from about 80 to about 1600 mg/day, or from about 200 to about 1600
mg/day, or from about 400 to about 1600 mg/day, or from about 400
to about 1200 mg/day, or from about 400 to about 1000 mg/day, or
from about 400 to about 800 mg/day, or from about 400 to about 600
mg/day. Doses are administered as a single dose (qd) or in two
doses (BID). Within this embodiment, compound I-B is preferred.
Also, within this embodiment, compounds of formula (I), I-A or I-B
are dosed in such way as to deliver compound A in an amount of
about 120 mg/day to about 1200 mg/day for an administration period
of up to 5 days, on days 1-5, of a 28 day treatment cycle, followed
by a rest period of 23 days; or
compounds of formula (I), I-A or I-B are dosed in such way as to
deliver compound A in an amount of from about 400 to about 1200
mg/day for an administration period of up to 5 days, on days 1-5,
of a 28 day treatment cycle, followed by a rest period of 23 days;
or compounds of formula (I), I-A or I-B are dosed in such way as to
deliver compound A in an amount of from about 400 to about 800
mg/day for an administration period of up to 5 days, on days 1-5,
of a 28 day treatment cycle, followed by a rest period of 23 days;
or compounds of formula (I), I-A or I-B are dosed in such way as to
deliver compound A in an amount of from about 400 to about 600
mg/day for an administration period of up to 5 days, on days 1-5,
of a 28 day treatment cycle, followed by a rest period of 23 days;
or compounds of formula (I), I-A or I-B are dosed in such way as to
deliver compound A in an amount of about 120 mg/day to about 800
mg/day for an administration period of up to 5 days, on days 1-5,
of a 28 day treatment cycle, followed by a rest period of 23 days;
or compounds of formula (I), I-A or I-B are dosed in such way as to
deliver compound A in an amount of about 120 mg/day to about 600
mg/day for an administration period of up to 5 days, on days 1-5,
of a 28 day treatment cycle, followed by a rest period of 23 days;
or compounds of formula (I), I-A or I-B are dosed in such way as to
deliver compound A in an amount of about 120 mg/day to about 400
mg/day for an administration period of up to 5 days, on days 1-5,
of a 28 day treatment cycle, followed by a rest period of 23 days;
or compounds of formula (I), I-A or I-B are dosed in such way as to
deliver compound A in an amount of about 120 mg/day for an
administration period of up to 5 days, on days 1-5, of a 28 day
treatment cycle, followed by a rest period of 23 days; or compounds
of formula (I), I-A or I-B are dosed two times a day (BID) as 600
mg doses in order to deliver a total daily dose of about 1200 mg of
compound (A) to the patient.
[0048] Also, within these embodiments and if not explicitly
otherwise stated, doses are administered as a single dose (qd) or
in two doses (BID), and compound I-A or I-B are the preferred
compounds.
[0049] In another embodiment, cytarabine is combined with the
compounds of formula (I), I-A or I-B according to the following
regimens as required for two specific patient populations, i.e.:
[0050] 1) Patients with relapsed/refractory AML or with de novo AML
who have adverse features per European LeukemiaNet guidelines; or
patients who have had antecedent hematologic disorders which have
transformed to AML. Within this embodiment, cytarabine is dosed at
1 g/m.sup.2 as a single dose (qd) during 6 days as a 1-3 hour
intravenous (i.v.) infusion. [0051] 2) Patients with adverse
features per European LeukemiaNet guidelines who are considered
candidates for intensive chemotherapy treatment with standard doses
of cytarabine and anthracycline (daunorubicin or idarubicin)
regimen ("7+3 Induction regimen"). Within this embodiment,
cytarabine is dosed at 100-200 mg/m.sup.2 daily during 7 days as a
continuous intravenous infusion+daunorubicin 45 to 60 mg/m.sup.2;
or +idarubicin 12 mg/m.sup.2 intravenously daily for 3 days.
[0052] Within any of the embodiments 1) or 2) above, compounds of
formula (I), I-A or I-B are dosed as defined herein before. Also,
within any of the embodiments 1) or 2) above, compounds of formula
(I), I-A or I-B are dosed in such way as to deliver compound A in
an amount of from about 120 to about 1200 mg/day; or from about 400
to about 1200 mg/day for an administration period of up to 5 days,
on days 1-5, of a 28 day treatment cycle, followed by a rest period
of 23 days. Within this embodiment, compound I-B is preferred.
[0053] In yet another embodiment, the present invention provides a
method for the treatment of cancer, comprising administering to a
patient in need of such treatment a pharmaceutical product as
defined hereinbefore. Within this embodiment, the MDM2 inhibitor is
preferably selected from compound I-A of I-B. Dosage forms, dosages
and treatment schedules for compounds I-A or I-B and cytarabine are
preferably as described above. Also, within this embodiment the
cancer is a solid- or non-solid tumor, preferably the cancer is
Acute Myeloid Leukemia (AML).
[0054] In another embodiment, the present invention provides the
use of a compound of formula (I), preferably I-A or I-B, and
cytarabine for the manufacture of a medicament for the treatment of
cancer, in particular Acute Myeloid Leukemia (AML).
[0055] In another embodiment, the present invention provides a
pharmaceutical product comprising, a) as a first component a
compound of formula (I); and b) as a second component the compound
cytarabine, both administered iv once or twice a day, as a combined
preparation for the simultaneous or sequential use in the treatment
of cancer; characterized in that the dose of the compound of
formula (I) corresponds to a dose of compound (A) within the range
from about 50 to about 3000 mg/day, or from about 80 to about 2500
mg/day, or from about 80 to about 1600 mg/day, or from about 200 to
about 1600 mg/day, or from about 400 to about 1600 mg/day, or from
about 400 to about 1200 mg/day, or from about 400 to about 1000
mg/day, or from about 400 to about 800 mg/day, or from about 400 to
about 600 mg/day. Within this embodiment, the compound of formula
(I) preferably is the compound I-A or I-B, the cancer is AML, the
daily dose is from about 200 to about 1600 mg given once or twice a
day, and the dosage regimen for the compounds I-A or I-B is on day
1 to 5, followed by a 23 days rest period of a 28 days treatment
cycle. More preferably, within this embodiment, the compound of
formula (I) is the compound I-B, the cancer is AML, the daily dose
is about 1200 mg given once or twice (BID, 600 mg) a day on day 1
to 5, followed by a 23 days rest period of a 28 days treatment
cycle.
[0056] The invention is now further illustrated by the following
accompanying working Example.
Example
Materials and Methods
[0057] Animals
[0058] Female SCID beige mice (10/group), obtained from Charles
River Laboratories (Wilmington, Del.) were used when they were
approximately 8-12 weeks old and weighed approximately 20-25 grams.
The health of the mice was assessed daily by gross observation and
analyses of blood samples taken from sentinel animals housed on
shared shelf racks. All animals were allowed to acclimate and
recover from any shipping-related stress for a minimum of 72 hours
prior to experimental use. Autoclaved water and irradiated food
(5058-ms Pico Lab mouse chow, Purina Mills, Richmond, Ind.) were
provided ad libitum, and the animals were maintained on a 12 hour
light and dark cycle. Cages, bedding and water bottles were
autoclaved before use and changed weekly. All animal experiments
were conducted in accordance with the Guide for the Care and Use of
Laboratory Animals, local regulations, and protocols approved by
the Roche Animal Care and Use Committee in an AAALAC accredited
facility.
[0059] Tumors
[0060] Parental MOLM-13 human AML cells were stably transfected
with Luc2 lentiviral particles for 24 hrs in the presence of
Polybrene (8 ug/ml) and then selected in the presence of
Blasticidin for 3 weeks. Subsequently, one clone was selected by
single cell plating in the presence of 0.1 mg/mL G418 and was
designated MOLM-13.luc.c4. The lentiviral Luc2 expression plasmid
was constructed by incorporating Luc2 gene (Promega) in to pLOC
lentiviral plasmid backbone (Thermo Fisher Scientific). Luc2
lentiviral particles were prepared by using Trans-Lentiviral
Packaging System (Thermo Fisher Scientific) as recommended.
[0061] MOLM-13.luc.c4 was maintained with RPMI 1640 with
L-glutamine (2 mM) media (GIBCO/Invitrogen, Carlsbad, Calif.)
supplemented with 10% heat-inactivated Fetal Bovine Serum (HI-FBS;
GIBCO/Invitrogen, Carlsbad, Calif.), and 1% 100 mM sodium pyruvate.
Freshly dissociated MOLM13-Luc.c4 cells (1.times.106 or
5.times.106) suspended in Phosphate Buffered Saline (PBS) were then
intravenously inoculated via the caudal tail vein into female
SCID-beige mice.
[0062] Test Agent
[0063]
4-{[(2R,3S,4R,5S)-3-(3-Chloro-2-fluoro-phenyl)-4-(4-chloro-2-fluoro-
-phenyl)-4-cyano-5-(2,2-dimethyl-propyl)-pyrrolidine-2-carbonyl]-amino}-3--
methoxy-benzoic acid 1-mPEG-carbonyloxy-ethyl ester (mPEG, average
MW, .about.2200), i.e. compound I-B, was dissolved in 0.9% sodium
chloride in sterile water by vortexing. It was then filtered thru a
0.22 micron filter into a septum sealed vial for intravenous
administration. Dose of the drug of 437 mg/kg is equivalent to 100
mg/kg of parent MDM2 inhibitor due to 22.88% active compound
loading in the prodrug. Stock cytarabine (Ara-C injection, 100
mg/ml) was diluted in sterile 0.9% sodium chloride to 44 mg/ml
according to manufacturer's instructions and dosed at 200 mg/kg iv
twice weekly.
[0064] Compound I-B and cytarabine were administered iv using a 1
cc syringe and 26-gauge needle at 437 mg/kg (9 ml/kg) weekly (q7d)
and 200 mg/kg (4.5 ml/kg) bi-weekly (2.times./week), respectively.
On days of concomitant administration, compound I-B was dosed in
the morning and cytarabine was administered 6 hours later in
compliance with IACUC regulations for intravenous volume
administration. Treatment duration was 3 weeks.
[0065] Monitoring
[0066] For increased life span (ILS) assessment, animal body
weights were measured two to three times per week, and animals were
monitored daily for any clinical signs of toxicity or excessive
tumor burden (i.e. hind limb paralysis or morbidity). In addition,
progression of disease was monitored by in vivo bioluminescent
imaging (BLI) using IVIS.RTM. Spectrum system. For each BLI
session, mice received 100 mg/kg D-luciferin (Caliper Life
Sciences/Perkin-Elmer) via ip injections and were imaged at 20 min
post luciferin injection at either a 5 s or a 10 s exposure time.
Images were captured by the IVIS.RTM. Spectrum system and data were
collected and analyzed with Living Image 4.2.0 software (Caliper
Life Sciences, Hopkinton, Mass.). Total photon fluxes (ph/s)
representing luciferase activity within each fixed region of
interest (ROI) covering whole tumors of individual mice were
determined. The actual images of mice are not disclosed herein.
Data for quantification of bioluminescence originated from this
monitoring are provided in FIG. 1.
[0067] Calculations & Statistical Analysis
[0068] Weight loss was graphically represented as percent change in
mean group body weight, using the formula:
((W-W.sub.0)/W.sub.0).times.100, where `W` represents mean body
weight of the treated group at a particular day, and `W.sub.0`
represents mean body weight of the same treated group at initiation
of treatment. Maximum weight loss was also represented using the
above formula, and indicated the maximum percent body weight loss
that was observed at any time during the entire experiment for a
particular group. Toxicity is defined as .gtoreq.20% of mice in a
given group demonstrating .gtoreq.20% body weight loss and/or
death.
[0069] Quantification of bioluminescence allowed for direct
longitudinal comparison of tumor burden between treatment groups
prior to surrogate death end points being reached. Tumor burden was
graphically represented as the mean BLI photon flux+standard error
of the mean (SEM), and median survival was determined utilizing
Kaplan Meier survival analysis. Statistical analysis of comparisons
between groups was analyzed by two-way ANOVA, and post-hoc
Bonferroni test (GraphPad Prism, version 4.3). Differences between
groups were considered to be significant when the probability value
(p) was .ltoreq.0.05.
[0070] For survival assessment, morbidity or hind limb paralyses
were monitored as end points and results were plotted as the
percentage survival against days after tumor implant (GraphPad
Prism, version 4.3). Hind limb paralysis, morbidity or .gtoreq.20%
body weight loss were used as surrogates for death. The % ILS was
calculated as 100.times.[(median survival day of treated
group-median survival day of control group)/median survival day of
control group]. Median survival was determined utilizing Kaplan
Meier survival analysis. Survival in treated groups was compared
with the vehicle group by Log-rank (Mantel-Cox) Test (GraphPad
Prism, version 4.3). Differences between groups were considered
significant when the probability value (p) was .ltoreq.0.05.
Results
[0071] Toxicity
[0072] Toxicity as assessed by animal body weight loss or gross
clinical signs was not observed in the current studies. There were
however, sporadic deaths directly after iv dosing of compound I-B
of undetermined cause (potentially technical, though unproven, see
Table 1).
TABLE-US-00001 TABLE 1 Summary of Toxicity data % Change # of ani-
Reason in Body mals .gtoreq.20% for Fre- Weight at body Mor-
Mortality/ Group quency Route Day 17 weight loss tality Morbidity
Vehicle q7d + iv + -4.9 0 0 N/A Control 2x/wk iv compound q7d iv
-2.8 0 1 Undeter- I-B 437 mined mg/kg Ara-C 200 2x/week iv -5.8 0 0
N/A mg/kg compound q7d + iv + -6.1 0 2 Undeter- I-B 437 2x/week iv
mined mg/kg + Ara-C 200 mg/kg
[0073] Antitumor Efficacy and Assessment of Survival/Increase in
Life Span (ILS)
[0074] Mice were inoculated with 5 million cells and drug treatment
was initiated on day 3. BLI demonstrated significantly reduced
photon counts for mice receiving compound I-B monotherapy, whereas
cytarabine (Ara-C) by itself showed no difference compared to
Vehicle-treated control mice (see FIG. 1). These apparent
reductions in tumor burden as assessed by BLI did translate into
significant increases in lifespan, with 37% ILS observed for groups
treated with q7d 437 mg/kg compound I-B. Cytarabine (Ara-C)
demonstrated a lack of antitumor activity as assessed by tumor
burden (BLI) or ILS. On the other hand, combinations with Ara-C and
compound I-B elicited statistically significant % ILS as compared
with Vehicle control or monotherapy arm, demonstrating a clear
enhancement of antitumor activity in combination. These data are
summarized in Table 2 below, also including a comparison with
orally administered compound (A).
TABLE-US-00002 TABLE 2 Summary of Efficacy data Cpd I-B Cpd (A) Cpd
(A) Ara-C Cpd I-B Cpd (A) Cpd (A) 437 100 80 200 437 mg/kg + 100
mg/kg + 80 mg/kg + Vehicle mg/kg mg/kg mg/kg mg/kg Ara-C 200 Ara-C
Ara-C Group Control q7d iv q7d po qd x 5 po 2x/wk iv mg/kg 200
mg/kg 200 mg/kg Median 20.5 28 25 28 20 31.5 26 34.5 survival
(days) % ILS -- *37 *22 *37 0 *.dagger.54 *.dagger.27 *.dagger.68
vs. Vehicle control *p < 0.05 Vs. Vehicle Control .dagger.p <
0.05 Vs. Monotherapy Arms Cpd = compound
* * * * *
References