U.S. patent application number 16/249274 was filed with the patent office on 2019-10-17 for dosage regimen for sapacitabine and decitabine in combination for treating acute myeloid leukemia.
The applicant listed for this patent is Cyclacel Limited. Invention is credited to Judy H. CHIAO.
Application Number | 20190314396 16/249274 |
Document ID | / |
Family ID | 46022492 |
Filed Date | 2019-10-17 |
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United States Patent
Application |
20190314396 |
Kind Code |
A1 |
CHIAO; Judy H. |
October 17, 2019 |
DOSAGE REGIMEN FOR SAPACITABINE AND DECITABINE IN COMBINATION FOR
TREATING ACUTE MYELOID LEUKEMIA
Abstract
A first aspect of the invention relates to a method of treating
AML in a subject, said method comprising administering to a subject
a therapeutically effective amount of (i) sapacitabine, or a
metabolite thereof; and (ii) decitabine; in accordance with a
dosing regimen comprising at least one first treatment cycle and at
least one second treatment cycle, wherein said first treatment
cycle comprises administering a therapeutically effective amount of
decitabine for 5 to 10 consecutive days followed by a rest period
of from 3 to 5 weeks, or until treatment-related toxicities are
resolved, whichever is longer; and wherein said second treatment
cycle comprises administering a therapeutically effective amount of
sapacitabine, or a metabolite thereof, for 3 consecutive days per
week, for 2 weeks followed by a rest period of from 2 to 4 weeks,
or until treatment-related toxicities are resolved, whichever is
longer.
Inventors: |
CHIAO; Judy H.; (Berkeley
Heights, NJ) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Cyclacel Limited |
London |
|
GB |
|
|
Family ID: |
46022492 |
Appl. No.: |
16/249274 |
Filed: |
January 16, 2019 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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14111430 |
Dec 17, 2013 |
10226478 |
|
|
PCT/GB2012/050815 |
Apr 13, 2012 |
|
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16249274 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 31/706 20130101;
A61K 31/7068 20130101; A61P 35/02 20180101; A61K 31/7068 20130101;
A61K 2300/00 20130101; A61K 31/706 20130101; A61K 2300/00
20130101 |
International
Class: |
A61K 31/7068 20060101
A61K031/7068; A61K 31/706 20060101 A61K031/706 |
Foreign Application Data
Date |
Code |
Application Number |
Apr 14, 2011 |
GB |
1106339.3 |
Oct 13, 2011 |
GB |
1117693.0 |
Dec 8, 2011 |
GB |
1121105.9 |
Claims
1-24. (canceled)
25. A kit of parts comprising: (i) sapacitabine, or a metabolite
thereof; (ii) decitabine; and (iii) instructions for administering
sapacitabine, or a metabolite thereof, and decitabine in accordance
with a dosing regimen comprising at least one first treatment cycle
and at least one second treatment cycle, wherein said first
treatment cycle comprises administering a therapeutically effective
amount of decitabine for 5 to 10 consecutive days followed by a
rest period of from 3 to 5 weeks, or until treatment-related
toxicities are resolved, whichever is longer; and wherein said
second treatment cycle comprises administering a therapeutically
effective amount of sapacitabine, or a metabolite thereof, for 3
consecutive days per week, for 2 weeks followed by a rest period of
from 2 to 4 weeks, or until treatment-related toxicities are
resolved, whichever is longer.
26. A kit of parts comprising: (i) sapacitabine, or a metabolite
thereof; (ii) decitabine; and (iii) instructions for administering
sapacitabine, or a metabolite thereof, and decitabine in accordance
with a dosing regimen comprising at least one first treatment cycle
and at least one second treatment cycle, wherein said first
treatment cycle comprises administering decitabine intravenously in
a dose of about 20 mg/m.sup.2 for 5 to 10 consecutive days followed
by a 3 to 5 week rest period, or until treatment-related toxicities
are resolved, whichever is longer; and wherein said second
treatment cycle comprises administering sapacitabine orally in a
dose of about 300 mg b.i.d. for 3 consecutive days per week, for 2
weeks followed by a 2 to 4 week rest period, or until
treatment-related toxicities are resolved, whichever is longer.
27. (canceled)
28. The kit of parts according to claim 25, wherein the decitabine
is formulated for intravenous administration.
29. The kit of parts according to claim 28, wherein the decitabine
is formulated for administration of 10 to 20 mg/m.sup.2 per day for
5 to 10 days.
30. The kit of parts according to claim 29, wherein the decitabine
is formulated for administration of 15 mg/m.sup.2 per day for 5 to
10 days.
31. The kit of parts according to claim 29, wherein the decitabine
is formulated for administration of 20 mg/m.sup.2 per day for 5
days.
32. The kit of parts according to claim 28, wherein the decitabine
is formulated for administration of 20 mg/m.sup.2 per day for 10
days.
33. The kit of parts according to claim 28, wherein the decitabine
is formulated in unit dosage form.
34. The kit of parts according to claim 25, wherein the
sapacitabine, or metabolite thereof, is formulated for oral
administration.
35. The kit of parts according to claim 34, wherein the
sapacitabine, or metabolite thereof, is administered as a single
dose per day.
36. The kit of parts according to claim 34, wherein the
sapacitabine, or metabolite thereof, is divided into separate
dosages for administration two, three or four times per day.
37. The kit of parts according to claim 34, wherein the
sapacitabine, or metabolite thereof, is administered twice per day
(b.i.d.).
38. The kit of parts according to claim 34, wherein the
sapacitabine, or metabolite thereof, is formulated for oral
administration of 100-800 mg per day.
39. The kit of parts according to claim 35, wherein the
sapacitabine, or metabolite thereof, is formulated for oral
administration of 100-400 mg per day.
40. The kit of parts according to claim 35, wherein the
sapacitabine, or metabolite thereof, is formulated for oral
administration of 250-300 mg per day.
41. The kit of parts according to claim 35, wherein the
sapacitabine, or metabolite thereof, is formulated for oral
administration of 300 mg per day.
42. The kit of parts according to claim 34, wherein the
sapacitabine, or metabolite thereof, is in unit dosage form.
43. The kit of parts according to claim 42, wherein the unit dosage
form of the sapacitabine, or metabolite thereof, is a pill, tablet,
gellule, drop or capsule.
44. The kit of parts according to claim 25, wherein the metabolite
of sapacitabine is
1-(2-C-Cyano-2-deoxy-.beta.-D-arabino-pentafuranosyl)-cytosine
(CNDAC).
45. The kit of parts according to claim 25, wherein each of (i) the
sapacitabine or metabolite thereof, and (ii) the decitabine, are
present in an amount sufficient for two or more of each treatment
cycle.
46. The kit of parts according to claim 25, wherein each of (i) the
sapacitabine or a metabolite thereof, and (ii) the decitabine, are
present in an amount sufficient for two to four of each treatment
cycle.
47. The kit of parts according to claim 25, for use in treating
acute myeloid leukemia (AML) in a subject.
48. The kit of parts according to claim 47, wherein the subject is
70 years of age or over.
49. The kit of parts according to claim 26, wherein the decitabine
is formulated in unit dosage form.
50. The kit of parts according to claim 26, wherein the
sapacitabine or metabolite thereof is formulated in unit dosage
form.
51. The kit of parts according to claim 26, wherein the metabolite
of sapacitabine is
1-(2-C-Cyano-2-deoxy-.beta.-D-arabino-pentafuranosyl)-cytosine
(CNDAC).
52. The kit of parts according to claim 26, wherein each of (i) the
sapacitabine or metabolite thereof, and (ii) the decitabine, are
present in an amount sufficient for two or more of each treatment
cycle.
53. The kit of parts according to claim 26, wherein each of (i) the
sapacitabine or a metabolite thereof, and (ii) the decitabine, are
present in an amount sufficient for two to four of each treatment
cycle.
54. The kit of parts according to claim 26, for use in treating
acute myeloid leukemia (AML) in a subject.
55. The kit of parts according to claim 26, wherein the subject is
70 years of age or over.
Description
RELATED APPLICATIONS
[0001] The present application is a divisional of U.S. patent
application Ser. No. 14/111,430, filed Dec. 17, 2013, which is a 35
U.S.C. 371 National Stage Filing of International Application
PCT/GB2012/050815, filed Apr. 13, 2012, which claims priority to GB
Application No. 1121105.9, filed Dec. 8, 2011, GB Application No.
1117693.0, filed Oct. 13, 2011 and GB Application No. 1106339.3,
filed Apr. 14, 2011. The contents of the aforementioned
applications are hereby incorporated by reference in their
entirety.
FIELD OF THE INVENTION
[0002] The present invention relates to a new dosing regimen
suitable for the treatment of cancer and other proliferative
disorders.
BACKGROUND TO THE INVENTION
[0003] DNA methyltransferases are a family of enzymes that promote
the covalent addition of a methyl group to a specific nucleotide
base in a molecule of DNA. All the known DNA methyltransferases use
S-adenosyl methionine (SAM) as the methyl donor. Four active DNA
methyltransferases have been identified in mammals. They are named
DNMT1, DNMT2, DNMT3A and DNMT3B.
[0004] DNMT1 is the most abundant DNA methyltransferase in
mammalian cells and considered to be the key maintenance
methyltransferase in mammals. It predominantly methylates
hemimethylated CpG di-nucleotides in the mammalian genome and is
responsible for maintaining methylation patterns established in
development. The enzyme is about 1620 amino acids long, the first
1100 amino acids constituting the regulatory domain, and the
remaining residues constituting the catalytic domain. These are
joined by Gly-Lys repeats. Both domains are required for the
catalytic function of DNMT1. DNMT3 is a family of DNA
methyltransferases that can methylate hemimethylated and
unmethylated CpG at the same rate. The architecture of DNMT3
enzymes is similar to DNMT1 with a regulatory region attached to a
catalytic domain.
[0005] Recent work has revealed how DNA methylation and chromatin
structure are linked at the molecular level and how methylation
anomalies play a direct causal role in tumorigenesis and genetic
disease. Much new information has also come to light regarding DNA
methyltransferases, in terms of their role in mammalian development
and the types of proteins they are known to interact with. Rather
than enzymes that act in isolation to copy methylation patterns
after replication, the types of interactions discovered thus far
indicate that DNA methyltransferases may be components of larger
complexes actively involved in transcriptional control and
chromatin structure modulation. These findings should enhance the
understanding of the myriad roles of DNA methylation in disease, as
well as leading to novel therapies for preventing or repairing
these defects.
[0006] Small molecule DNA methyltransferase inhibitors are well
documented in the art and include, for example, decitabine,
azacitabine, zebularine, procainamide, procaine, hydralazine,
((-)-epigallocatechin-3-gallate (EGCG) and RG108.
[0007] Decitabine or 5-aza-2'-deoxycytidine (trade name Dacogen) is
the compound
4-amino-1-(2-deoxy-b-D-erythro-pentofuranosyl)-1,3,5-triazin-2(1-
H)-one.
[0008] Azacitidine (trade name Vidaza) is the compound
4-amino-1-.beta.-D-ribofuranosyl-s-triazin-2(1H)-one, the structure
of which is shown below.
##STR00001##
[0009] Azacitidine is an anti-neoplastic pyrimidine nucleoside
analog used to treat several subtypes of myelodysplastic syndrome,
diseases caused by abnormalities in the blood-forming cells of the
bone marrow which result in underproduction of healthy blood cells.
The drug exerts a cytotoxic effect on rapidly dividing cells,
including cancerous cells, and may help restore normal function to
genes controlling proper cellular differentiation and
proliferation.
[0010] Azacitidine is specifically indicated for the treatment of
the following myelodysplastic syndrome subtypes: refractory anemia,
refractory anemia with ringed sideroblasts (if accompanied by
neutropenia or thrombocytopenia or requiring transfusions),
refractory anemia with excess blasts, refractory anemia with excess
blasts in transformation and chronic myelomonocytic leukemia.
[0011] Azacitidine is believed to exert its antineoplastic effects
by causing hypomethylation of DNA and direct cytotoxicity on
abnormal haematopoietic cells in the bone marrow. The concentration
of azacitidine required for maximum inhibition of DNA methylation
in vitro does not cause major suppression of DNA synthesis.
Hypomethylation may restore function to genes that are critical for
differentiation or proliferation. The cytotoxic effects of
azacitidine cause the death of rapidly dividing cells, including
cancer cells that are no longer responsive to normal growth control
mechanisms. Non-proliferating cells are relatively insensitive to
azacitidine.
[0012] Another known DNA methyltransferase inhibitor is zebularine,
also known as 1-(.beta.-D-ribofuranosyl)-1,2-dihydropyrimidin-2-one
or 2-pyrimidone-1-.beta.-D-riboside, the structure of which is
shown below.
##STR00002##
[0013] Other known DNA methyltransferase inhibitors are
non-nucleoside analogues, for example, procainamide, procaine,
hydralazine and ((-)-epigallocatechin-3-gallate (EGCG).
[0014] Procainamide (trade names Pronestyl, Procan, Procanbid) is
the compound 4-amino-N-(2-diethylaminoethyl)benzamide, the
structure of which is shown below.
##STR00003##
[0015] Procainamide has been shown to inhibit DNA methyltransferase
activity and reactivate silenced gene expression in cancer cells by
reversing CpG island hypermethylation. Procainamide specifically
inhibits the hemimethylase activity of DNA methyltransferase 1
(DNMT1), the mammalian enzyme thought to be responsible for
maintaining DNA methylation patterns during replication.
[0016] Procaine is the compound
2-(diethylamino)ethyl-4-aminobenzoate, the structure of which is
shown below.
##STR00004##
[0017] Procaine is a DNA-demethylating agent that is understood to
inhibit DNA methyltransferases by interfering with enzyme
activity.
[0018] Hydralazine (Apresoline) is the compound
1-hydrazinophthalazine monohydrochloride, the structure of which is
shown below.
##STR00005##
[0019] ((-)-Epigallocatechin-3-gallate (EGCG) is a catechin
analogue having the structure shown below.
##STR00006##
[0020] EGCG is understood to inhibit DNMT activity and reactivate
methylation-silenced genes in cancer cells.
[0021] Another known DNA methyltransferase inhibitor is RG108, also
known as N-phthalyl-1-tryptophan, the structure of which is shown
below.
##STR00007##
[0022] RG108 is a DNA methyltransferase inhibitor that is
understood to inhibit DNA methyltransferases by interfering with
enzyme activity. In particular, RG108 is believed to reactivate
tumor suppressor gene expression (p16, SFRP1, secreted frizzled
related protein-1, and TIMP-3) in tumor cells by DNA demethylation.
RG108 also inhibits human tumor cell line (HCT116, NALM-6)
proliferation and increases doubling time in culture.
[0023] It is well established in the art that active pharmaceutical
agents can often be given in combination in order to optimise the
treatment regime.
[0024] Qin T et al (2007, 13, Clin. Cancer Res. 4225-4232) disclose
the effect of combinations of cytarabine and decitabine in various
human leukemic cell lines. Likewise, Kong X B et al (1991,
Molecular Pharmacol. 39, 250-257) suggest that 5-azacitidine causes
upregulation of dCK in a cell line that is resistant to cytarabine,
resulting in a decrease in the IC.sub.50 value for cytarabine from
12.5 to 0.55 .mu.M.
[0025] Combinations of DNA methyltransferase inhibitors and
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine (also known as "CYC682" or sapacitabine), or a metabolite
thereof, are described in WO 2009/150405 (Cyclacel Limited).
Pharmaceutical compositions comprising such combinations, and their
use in treating various proliferative disorders are also described
in WO 2009/150405.
[0026] The present invention seeks to provide a new dosing regimen
for known pharmaceutical agents that is particularly suitable for
the treatment of proliferative disorders, especially acute myeloid
leukemia (AML). More specifically, the invention centres on the
surprising and unexpected effects associated with using certain
pharmaceutical agents in combination.
SUMMARY OF THE INVENTION
[0027] A first aspect of the invention relates to a method of
treating AML in a subject, said method comprising administering to
a subject a therapeutically effective amount of (i) sapacitabine,
or a metabolite thereof; and (ii) decitabine; in accordance with a
dosing regimen comprising at least one first treatment cycle and at
least one second treatment cycle, [0028] wherein said first
treatment cycle comprises administering a therapeutically effective
amount of decitabine for 5 to 10 consecutive days followed by a
rest period of from 3 to 5 weeks, or until treatment-related
toxicities are resolved, whichever is longer; and [0029] wherein
said second treatment cycle comprises administering a
therapeutically effective amount of sapacitabine, or a metabolite
thereof, for 3 consecutive days per week, for 2 weeks followed by a
rest period of from 2 to 4 weeks, or until treatment-related
toxicities are resolved, whichever is longer.
[0030] A second aspect of the invention relates to a method of
treating AML in an elderly subject, said method comprising
administering to a subject a therapeutically effective amount of
(i) sapacitabine; and (ii) decitabine; in accordance with a dosing
regimen comprising at least one first treatment cycle and at least
one second treatment cycle, [0031] wherein said first treatment
cycle comprises administering decitabine intravenously in a dose of
about 20 mg/m.sup.2 for 5 to 10 consecutive days followed by a 3 to
5 week rest period, or until treatment-related toxicities are
resolved, whichever is longer; and [0032] wherein said second
treatment cycle comprises administering sapacitabine orally in a
dose of about 300 mg b.i.d. for 3 consecutive days per week, for 2
weeks followed by a 2 to 4 week rest period, or until
treatment-related toxicities are resolved, whichever is longer.
[0033] A third aspect of the invention relates to (i) sapacitabine,
or a metabolite thereof; and (ii) decitabine; for use in treating
AML, wherein the sapacitabine, or a metabolite thereof, and the
decitabine are administered in accordance with a dosing regimen
comprising at least one first treatment cycle and at least one
second treatment cycle, [0034] wherein said first treatment cycle
comprises administering a therapeutically effective amount of
decitabine for 5 to 10 consecutive days followed by a rest period
of from 3 to 5 weeks, or until treatment-related toxicities are
resolved, whichever is longer; and [0035] wherein said second
treatment cycle comprises administering a therapeutically effective
amount of sapacitabine, or a metabolite thereof, for 3 consecutive
days per week, for 2 weeks followed by a rest period of from 2 to 4
weeks, or until treatment-related toxicities are resolved,
whichever is longer.
[0036] A fourth aspect of the invention relates to (i)
sapacitabine, or a metabolite thereof; and (ii) decitabine; for use
in treating AML in an elderly subject, wherein the sapacitabine, or
metabolite thereof, and decitabine, are administered in accordance
with a dosing regimen comprising at least one first treatment cycle
and at least one second treatment cycle, [0037] wherein said first
treatment cycle comprises administering decitabine intravenously in
a dose of about 20 mg/m.sup.2 per day for 5 to 10 consecutive days
followed by a 3 to 5 week rest period, or until treatment-related
toxicities are resolved, whichever is longer; and [0038] wherein
said second treatment cycle comprises administering sapacitabine
orally in a dose of about 300 mg b.i.d. for 3 consecutive days per
week, for 2 weeks followed by a 2 to 4 week rest period, or until
treatment-related toxicities are resolved, whichever is longer.
[0039] A fifth aspect of the invention relates to the use of (i)
sapacitabine, or a metabolite thereof; and (ii) decitabine; in the
preparation of a medicament for treating AML, wherein the
sapacitabine, or a metabolite thereof, and the decitabine are
administered in accordance with a dosing regimen comprising at
least one first treatment cycle and at least one second treatment
cycle, [0040] wherein said first treatment cycle comprises
administering a therapeutically effective amount of decitabine for
5 to 10 consecutive days followed by a rest period of from 3 to 5
weeks, or until treatment-related toxicities are resolved,
whichever is longer; and [0041] wherein said second treatment cycle
comprises administering a therapeutically effective amount of
sapacitabine, or a metabolite thereof, for 3 consecutive days per
week, for 2 weeks followed by a rest period of from 2 to 4 weeks,
or until treatment-related toxicities are resolved, whichever is
longer.
[0042] A sixth aspect of the invention relates to the use of (i)
sapacitabine, or a metabolite thereof; and (ii) decitabine; in the
preparation of a medicament for treating AML in an elderly subject,
wherein the sapacitabine, or metabolite thereof, and decitabine,
are administered in accordance with a dosing regimen comprising at
least one first treatment cycle and at least one second treatment
cycle, [0043] wherein said first treatment cycle comprises
administering decitabine intravenously in a dose of about 20
mg/m.sup.2 per day for 5 to 10 consecutive days followed by a 3 to
5 week rest period, or until treatment-related toxicities are
resolved, whichever is longer; and [0044] wherein said second
treatment cycle comprises administering sapacitabine orally in a
dose of about 300 mg b.i.d. for 3 consecutive days per week, for 2
weeks followed by a 2 to 4 week rest period, or until
treatment-related toxicities are resolved, whichever is longer.
[0045] A seventh aspect of the invention relates to a kit of parts
comprising:
(i) sapacitabine, or a metabolite thereof; (ii) decitabine; and
(iii) instructions for administering sapacitabine, or a metabolite
thereof, and decitabine in accordance with a dosing regimen
comprising at least one first treatment cycle and at least one
second treatment cycle, [0046] wherein said first treatment cycle
comprises administering a therapeutically effective amount of
decitabine for 5 to 10 consecutive days followed by a rest period
of from 3 to 5 weeks, or until treatment-related toxicities are
resolved, whichever is longer; and [0047] wherein said second
treatment cycle comprises administering a therapeutically effective
amount of sapacitabine, or a metabolite thereof, for 3 consecutive
days per week, for 2 weeks followed by a rest period of from 2 to 4
weeks, or until treatment-related toxicities are resolved,
whichever is longer.
[0048] An eighth aspect of the invention relates to a kit of parts
comprising:
(i) sapacitabine, or a metabolite thereof; (ii) decitabine; and
(iii) instructions for administering sapacitabine, or a metabolite
thereof, and decitabine in accordance with a dosing regimen
comprising at least one first treatment cycle and at least one
second treatment cycle, [0049] wherein said first treatment cycle
comprises administering decitabine intravenously in a dose of about
20 mg/m.sup.2 for 5 to 10 consecutive days followed by a 3 to 5
week rest period, or until treatment-related toxicities are
resolved, whichever is longer; and [0050] wherein said second
treatment cycle comprises administering sapacitabine orally in a
dose of about 300 mg for 3 consecutive days per week, for 2 weeks
followed by a 2 to 4 week rest period, or until treatment-related
toxicities are resolved, whichever is longer.
DESCRIPTION OF THE DRAWINGS
[0051] FIG. 1A is a bar graph showing the effect of azacitidine in
combination with CNDAC on the cell cycle profile and induction of
apoptosis in HL60 cells treated with 128 nM azacitidine for 24
hours followed by 128 nM azacitidine and 133 nM CNDAC for a further
48 hours, for a total of 72 hours. Cells were fixed and DNA stained
with propidium iodide. Single agent controls were also included.
Data is the average of two samples and representative of at least
two independent experiments.
[0052] FIG. 1B is a bar graph showing the effect of azacitidine in
combination with CNDAC on the cell cycle profile and induction of
apoptosis in HL60 cells treated with 128 nM azacitidine for 24
hours followed by 128 nM azacitidine and 133 nM CNDAC for a further
48 hours, for a total of 72 hours. Cells were stained with annexin
V that detected apoptotic cells and propidium iodide to detect
viable cells. Single agent controls were also included. Data is the
average of two samples and representative of at least two
independent experiments.
[0053] FIG. 2A is a bar graph showing the effect of azacitidine in
combination with CNDAC on the cell cycle profile and induction of
apoptosis in HL60 cells treated with 128 nM azacitidine for 24
hours followed by 128 nM azacitidine and 133 nM CNDAC for a further
72 hours, for a total of 96 hours. Cells were fixed and DNA stained
with propidium iodide. Single agent controls were also included.
Data is the average of two samples and representative of at least
two independent experiments.
[0054] FIG. 2B is a bar graph showing the effect of azacitidine in
combination with CNDAC on the cell cycle profile and induction of
apoptosis in HL60 cells treated with 128 nM azacitidine for 24
hours followed by 128 nM azacitidine and 133 nM CNDAC for a further
72 hours, for a total of 96 hours. Cells were stained with annexin
V that detected apoptotic cells and propidium iodide to detect
viable cells. Single agent controls were also included. Data is the
average of two samples and representative of at least two
independent experiments.
[0055] FIG. 3 depicts a time course showing the effect of CNDAC and
azacitidine alone or in combination on molecular events in HL60
cells. HL60 cells were treated as follows: mock treated with DMSO
(D); treated with azacitidine only (0.5.times.IC.sub.50: 128 nM)
(A); treated with media for 24 hours followed by CNDAC (lx
IC.sub.50: 133 nM) (C); or azacitidine (128 nM) for 24 h followed
by CNDAC (133 nM) (AC). Samples were collected at various times
(indicated) after CNDAC addition. Cells were lysed, fractionated by
SDS-PAGE, transferred to nitrocellulose and probed for cleaved PARP
(a marker of apoptosis). Data is representative of two independent
experiments.
DETAILED DESCRIPTION
[0056] The effect of drug combinations is inherently unpredictable
and there is often a propensity for one drug to partially or
completely inhibit the effects of the other. The present invention
is based on the surprising observation that administering
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine and decitabine in accordance with a particular dosing
regimen does not lead to any adverse interaction between the two
agents. The unexpected absence of any such antagonistic interaction
is critical for clinical applications.
[0057] In a preferred embodiment, the dosing regimen of the
invention produces an enhanced effect as compared to either drug
administered alone. The surprising nature of this observation is in
contrast to that expected on the basis of the prior art.
[0058] Moreover, the presently claimed dosing regimen is well
tolerated and gives rise to excellent response rates, good overall
survival rates and absence of overlapping or cumulative
toxicities.
[0059]
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N.sup.4-palmi-
toyl cytosine (I), also known as
2'-cyano-2-deoxy-N.sup.4-palmiotoyl-1-.beta.-D-arabinofuranosylcytosine
(Hanaoka, K., et al, Int. J. Cancer, 1999:82:226-236; Donehower R,
et al, Proc Am Soc Clin Oncol, 2000: abstract 764; Burch, P A, et
al, Proc Am Soc Clin Oncol, 2001: abstract 364), is an orally
administered novel 2'-deoxycytidine antimetabolite prodrug of the
nucleoside CNDAC,
1-(2-C-Cyano-2-deoxy-.beta.-D-arabino-pentafuranosyl)-cytosine.
##STR00008##
[0060]
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N.sup.4-palmi-
toyl cytosine (I) (also known as "CYC682" or sapacitabine) has a
unique mode of action over other nucleoside metabolites such as
gemcitabine in that it has a spontaneous DNA strand breaking
action, resulting in potent anti-tumour activity in a variety of
cell lines, xenograft and metastatic cancer model.
[0061]
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N.sup.4-palmi-
toyl cytosine (I) has been the focus of a number of studies in view
of its oral bioavailability and its improved activity over
gemcitabine (the leading marketed nucleoside analogue) and 5-FU (a
widely-used antimetabolite drug) based on preclinical data in solid
tumours. Recently, investigators reported that (I) exhibited strong
anticancer activity in a model of colon cancer. In the same model,
(I) was found to be superior to either gemcitabine or 5-FU in terms
of increasing survival and also preventing the spread of colon
cancer metastases to the liver (Wu M, et al, Cancer Research,
2003:63:2477-2482). To date, phase I data from patients with a
variety of cancers suggest that (I) is well tolerated in humans,
with myelosuppression as the dose limiting toxicity.
[0062] The DNA methyltransferase inhibitor used in the dosing
regimen of the present invention is decitabine. Decitabine or
5-aza-2'-deoxycytidine (trade name Dacogen) is the compound
4-amino-1-(2-deoxy-b-D-erythro-pentofuranosyl)-1,3,5-triazin-2(1H)-one,
the structure of which is shown below.
##STR00009##
[0063] Decitabine is indicated for the treatment of myelodysplastic
syndromes (MDS) including previously treated and untreated, de novo
and secondary MDS of all French-American-British subtypes
(refractory anemia, refractory anemia with ringed sideroblasts,
refractory anemia with excess blasts, refractory anemia with excess
blasts in transformation, and chronic myelomonocytic leukemia) and
Intermediate-1, Intermediate-2, and High-Risk International
Prognostic Scoring System groups.
[0064] Decitabine is believed to exert its antineoplastic effects
after phosphorylation and direct incorporation into DNA. Decitabine
inhibits DNA methyltransferase, causing hypomethylation of DNA and
cellular differentiation or apoptosis. Decitabine-induced
hypomethylation in neoplastic cells may restore normal function to
genes that are critical for the control of cellular differentiation
and proliferation. In rapidly dividing cells, the cytotoxicity of
decitabine may also be attributed to the formation of covalent
adducts between DNA methyltransferase and compound that has been
incorporated into DNA. Non-proliferating cells are relatively
insensitive to decitabine.
[0065] As used herein the phrase "preparation of a medicament"
includes the use of the components of the invention directly as the
medicament in addition to their use in any stage of the preparation
of such a medicament.
[0066] In one preferred embodiment, the decitabine and
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine are each administered in a therapeutically effective
amount with respect to the individual components; in other words,
the decitabine and
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine are administered in amounts that would be therapeutically
effective even if the components were administered other than in
combination.
[0067] In another preferred embodiment, the decitabine and
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine are each administered in a sub-therapeutic amount with
respect to the individual components; in other words, the
decitabine and
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine are administered in amounts that would be therapeutically
ineffective if the components were administered other than in
combination.
[0068] Preferably, the
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine and decitabine interact in a synergistic manner. As used
herein, the term "synergistic" means that
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine and the decitabine produce a greater effect when used in
combination than would be expected from adding the individual
effects of the two components. Advantageously, a synergistic
interaction may allow for lower doses of each component to be
administered to a patient, thereby decreasing the toxicity of
chemotherapy, whilst producing and/or maintaining the same
therapeutic effect. Thus, in a particularly preferred embodiment,
each component can be administered in a sub-therapeutic amount.
Specific Dosing Regimens for AML
[0069] Previous studies by the applicant have shown that in AML
cell lines, the active metabolite of sapacitabine, CNDAC, is
synergistic with hypomethylating agents and the synergy is more
apparent if cells are treated with hypomethylating agents
first.
[0070] One aspect of the invention therefore relates to a method of
treating AML in a subject, said method comprising administering to
a subject a therapeutically effective amount of (i) sapacitabine,
or a metabolite thereof; and (ii) decitabine; in accordance with a
dosing regimen comprising at least one first treatment cycle and at
least one second treatment cycle, [0071] wherein said first
treatment cycle comprises administering a therapeutically effective
amount of decitabine for 5 to 10 consecutive days followed by a
rest period of from 3 to 5 [0072] weeks, or until treatment-related
toxicities are resolved, whichever is longer; and wherein said
second treatment cycle comprises administering a therapeutically
effective amount of sapacitabine, or a metabolite thereof, for 3
consecutive days per week, for 2 weeks followed by a rest period of
from 2 to 4 weeks, or until treatment-related toxicities are
resolved, whichever is longer.
[0073] The preferred embodiments set forth below apply equally to
all aspects of the invention.
[0074] In one preferred embodiment, the second treatment cycle
comprises administering a therapeutically effective amount of
sapacitabine.
[0075] The sequential administration of decitabine and sapacitabine
in alternating cycles in accordance with the presently claimed
dosing regimen maximizes the efficacy of both drugs and minimizes
overlapping myelosuppression.
[0076] The first and second treatment cycles are repeated
sequentially with rest periods between sequential cycles, i.e.
there is a rest period between the last day of decitabine
administration and the first day of the second treatment cycle;
likewise there is a rest period between the last day of
sapacitabine administration and the first day of the next (first)
treatment cycle. Preferably, the rest period is sufficient so as to
resolve any treatment-related toxicities.
[0077] As used herein, treatment-related toxicities are mostly
myelosuppression and its associated complications.
[0078] In one preferred embodiment, the first treatment cycle
comprises administering a therapeutically effective amount of
decitabine for 5 consecutive days followed by a rest period of from
3 to 5 weeks, or until treatment-related toxicities are resolved,
whichever is longer.
[0079] In one preferred embodiment, the first treatment cycle
comprises administering a therapeutically effective amount of
decitabine for 5 days followed by a rest period of 3 to 5
weeks.
[0080] In a more preferred embodiment, the first treatment cycle
comprises administering a therapeutically effective amount of
decitabine for 5 days followed by a rest period of 3 weeks.
[0081] In one preferred embodiment, the first treatment cycle
comprises administering a therapeutically effective amount of
decitabine for 10 consecutive days followed by a rest period of
from 3 to 5 weeks, or until treatment-related toxicities are
resolved, whichever is longer.
[0082] In another preferred embodiment, the first treatment cycle
comprises administering a therapeutically effective amount of
decitabine for 10 days followed by a rest period of 4 weeks.
[0083] In one preferred embodiment, the second treatment cycle
comprises administering a therapeutically effective amount of
sapacitabine or metabolite thereof for 3 consecutive days per week,
for 2 weeks, followed by a rest period of 2 to 4 weeks.
[0084] In a more preferred embodiment, the second treatment cycle
comprises administering a therapeutically effective amount of
sapacitabine or metabolite thereof for 3 consecutive days per week,
for 2 weeks, followed by a rest period of 2 weeks.
[0085] In one preferred embodiment, the method comprises two or
more of each treatment cycle, more preferably, three or more, four
or more, or five or more of each treatment cycle.
[0086] In one highly preferred embodiment, the method comprises
four or more of each treatment cycle.
[0087] In one highly preferred embodiment, the method comprises two
to four of each treatment cycle.
[0088] In one preferred embodiment, the decitabine is administered
intravenously.
[0089] In one preferred embodiment, the decitabine is administered
in a dose of from about 10 to 20 mg/m.sup.2 per day.
[0090] In a more preferred embodiment, the decitabine is
administered in a dose of about 20 mg/m.sup.2 per day. In certain
preferred embodiments, the decitabine dosage may be tailored to
individual patients within the same schedule in order to mitigate
side effects. For example, in certain preferred embodiments the
decitabine dosage may be reduced (typically in 5 mg/m.sup.2
increments) from a starting dose of about 20 mg/m.sup.2 per day, to
about 15 mg/m.sup.2 per day, or to about 10 mg/m.sup.2 per day.
[0091] In one preferred embodiment, the decitabine is administered
over a period of up to 3 hours per day, more preferably over a
period of up to 2 hours per day, even more preferably over a period
of about 1 hour per day.
[0092] In one preferred embodiment, the first treatment cycle
comprises administering a therapeutically effective amount of
decitabine in a dosage of about 20 mg/m.sup.2 for 10 days, followed
by a rest period of 4 weeks.
[0093] In one preferred embodiment, the sapacitabine or metabolite
thereof is administered orally.
[0094] In one preferred embodiment, the sapacitabine or metabolite
thereof is administered in a dose of about 100-400 mg b.i.d., more
preferably from about 250-300 mg b.i.d.
[0095] In a more preferred embodiment, the sapacitabine or
metabolite thereof is administered in a dose of about 300 mg b.i.d.
In certain preferred embodiments, the sapacitabine dosage may be
tailored to individual patients within the same schedule in order
to mitigate side effects. For example, in certain preferred
embodiments the sapacitabine dosage may be reduced (typically in 50
mg increments) from a starting dose of about 300 mg b.i.d. to about
250 mg b.i.d., or to about 200 mg b.i.d., or to about 150 mg
b.i.d., or to about 100 mg b.i.d.
[0096] In one preferred embodiment, the subject is an elderly
subject. As used herein, the term "elderly subject" refers to a
subject of 60 years of age or over. More preferably, the subject is
65 years of age or over, even more preferably, 70 years of age or
over, more preferably still, 75 years of age or over.
[0097] A further aspect of the invention relates to a method of
treating AML in an elderly subject, said method comprising
administering to a subject a therapeutically effective amount of
(i) sapacitabine; and (ii) decitabine; in accordance with a dosing
regimen comprising at least one first treatment cycle and at least
one second treatment cycle, [0098] wherein said first treatment
cycle comprises administering decitabine intravenously in a dose of
about 20 mg/m.sup.2 per day for 5 consecutive days followed by a 3
to 5 week rest period, or until treatment-related toxicities are
resolved, whichever is longer; and [0099] wherein said second
treatment cycle comprises administering sapacitabine orally in a
dose of about 300 mg b.i.d. for 3 consecutive days per week, for 2
weeks followed by a 2 to 4 week rest period, or until
treatment-related toxicities are resolved, whichever is longer.
[0100] In one highly preferred embodiment, the dosing regimen
comprises administering decitabine at 20 mg/m.sup.2 per day for 5
consecutive days of a 4-week cycle (odd cycles) and sequentially
sapacitabine at 300 mg orally twice per day for three days per week
for two weeks of a 4-week cycle (even cycles).
[0101] A further aspect of the invention relates to a method of
treating AML in an elderly subject, said method comprising
administering to a subject a therapeutically effective amount of
(i) sapacitabine; and (ii) decitabine; in accordance with a dosing
regimen comprising at least one first treatment cycle and at least
one second treatment cycle, [0102] wherein said first treatment
cycle comprises administering decitabine intravenously in a dose of
about 20 mg/m.sup.2 per day for 10 consecutive days followed by a 3
to 5 week rest period, or until treatment-related toxicities are
resolved, whichever is longer; and [0103] wherein said second
treatment cycle comprises administering sapacitabine orally in a
dose of about 300 mg b.i.d. for 3 consecutive days per week, for 2
weeks followed by a 2 to 4 week rest period, or until
treatment-related toxicities are resolved, whichever is longer.
[0104] In one highly preferred embodiment, the dosing regimen
comprises administering decitabine at 20 mg/m.sup.2 per day for 10
consecutive days of a 4-week cycle (odd cycles) and sequentially
sapacitabine at 300 mg orally twice per day for three days per week
for two weeks of a 4-week cycle (even cycles).
[0105] A further aspect of the invention relates to (i)
sapacitabine, or a metabolite thereof; and (ii) decitabine; for use
in treating AML, wherein the sapacitabine, or metabolite thereof,
and the decitabine are administered in accordance with a dosing
regimen comprising at least one first treatment cycle and at least
one second treatment cycle, [0106] wherein said first treatment
cycle comprises administering a therapeutically effective amount of
decitabine for 5 or 10 consecutive days followed by a rest period
of from 3 to 5 weeks, or until treatment-related toxicities are
resolved, whichever is longer; and [0107] wherein said second
treatment cycle comprises administering a therapeutically effective
amount of sapacitabine, or a metabolite thereof, for 3 consecutive
days per week, for 2 weeks followed by a rest period of from 2 to 4
weeks, or until treatment-related toxicities are resolved,
whichever is longer.
[0108] Another aspect of the invention relates to (i) sapacitabine,
or a metabolite thereof; and (ii) decitabine; for use in treating
AML in an elderly subject, wherein the sapacitabine, or metabolite
thereof, and decitabine, are administered in accordance with a
dosing regimen comprising at least one first treatment cycle and at
least one second treatment cycle, [0109] wherein said first
treatment cycle comprises administering decitabine intravenously in
a dose of about 20 mg/m.sup.2 per day for 5 or 10 consecutive days
followed by a 3 to 5 week rest period, or until treatment-related
toxicities are resolved, whichever is longer; and [0110] wherein
said second treatment cycle comprises administering sapacitabine
orally in a dose of about 300 mg b.i.d. for 3 consecutive days per
week, for 2 weeks followed by a 2 to 4 week rest period, or until
treatment-related toxicities are resolved, whichever is longer.
[0111] A further aspect of the invention relates to the use of (i)
sapacitabine, or a metabolite thereof; and (ii) decitabine; in the
preparation of a medicament for treating AML, wherein the
sapacitabine, or metabolite thereof, and the decitabine are
administered in accordance with a dosing regimen comprising at
least one first treatment cycle and at least one second treatment
cycle, [0112] wherein said first treatment cycle comprises
administering a therapeutically effective amount of decitabine for
5 or 10 consecutive days followed by a rest period of from 3 to 5
weeks, or until treatment-related toxicities are resolved,
whichever is longer; and [0113] wherein said second treatment cycle
comprises administering a therapeutically effective amount of
sapacitabine, or a metabolite thereof, for 3 consecutive days per
week, for 2 weeks followed by a rest period of from 2 to 4 weeks,
or until treatment-related toxicities are resolved, whichever is
longer.
[0114] Another aspect of the invention relates to the use of (i)
sapacitabine, or a metabolite thereof; and (ii) decitabine; in the
preparation of a medicament for treating AML in an elderly subject,
wherein the sapacitabine, or metabolite thereof, and decitabine are
administered in accordance with a dosing regimen comprising at
least one first treatment cycle and at least one second treatment
cycle, [0115] wherein said first treatment cycle comprises
administering decitabine intravenously in a dose of about 20
mg/m.sup.2 per day for 5 or 10 consecutive days followed by a 3 to
5 week rest period, or until treatment-related toxicities are
resolved, whichever is longer; and [0116] wherein said second
treatment cycle comprises administering sapacitabine orally in a
dose of about 300 mg b.i.d. for 3 consecutive days per week, for 2
weeks followed by a 2 to 4 week rest period, or until
treatment-related toxicities are resolved, whichever is longer.
Kit of Parts
[0117] A further aspect of the invention relates to a kit of parts
comprising:
(i) sapacitabine, or a metabolite thereof; (ii) decitabine; and
(iii) instructions for administering sapacitabine, or a metabolite
thereof, and decitabine in accordance with a dosing regimen
comprising at least one first treatment cycle and at least one
second treatment cycle, [0118] wherein said first treatment cycle
comprises administering a therapeutically effective amount of
decitabine for 5 to 10 consecutive days followed by a rest period
of from 3 to 5 weeks, or until treatment-related toxicities are
resolved, whichever is longer; and [0119] wherein said second
treatment cycle comprises administering a therapeutically effective
amount of sapacitabine, or a metabolite thereof, for 3 consecutive
days per week, for 2 weeks followed by a rest period of from 2 to 4
weeks, or until treatment-related toxicities are resolved,
whichever is longer.
[0120] Another aspect of the invention relates to a kit of parts
comprising:
(i) sapacitabine, or a metabolite thereof; (ii) decitabine; and
(iii) instructions for administering sapacitabine, or a metabolite
thereof, and decitabine in accordance with a dosing regimen
comprising at least one first treatment cycle and at least one
second treatment cycle, [0121] wherein said first treatment cycle
comprises administering decitabine intravenously in a dose of about
20 mg/m.sup.2 for 5 to 10 consecutive days followed by a 3 to 5
week rest period, or until treatment-related toxicities are
resolved, whichever is longer; and [0122] wherein said second
treatment cycle comprises administering sapacitabine orally in a
dose of about 300 mg for 3 consecutive days per week, for 2 weeks
followed by a 2 to 4 week rest period, or until treatment-related
toxicities are resolved, whichever is longer.
[0123] Preferably, the kit of parts is for use in treating ALM in a
subject, preferably an elderly subject.
Metabolite
[0124] As used herein, the term "metabolite" encompasses chemically
modified entities that are produced by metabolism of
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine.
[0125] In one particularly preferred embodiment of the invention,
the metabolite of
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine is 2'-C'-cyano-2'-dioxy-1-.beta.-D-arabino-pentofuranosyl
cytosine (CNDAC).
[0126] In another particularly preferred embodiment of the
invention,
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine is metabolized intracellularly to the active metabolite
CNDAC-triphosphate (CNDACTP), a process involving both the cleavage
of the palmitoyl moiety and activation to CNDACTP by the action of
nucleoside kinases.
Salts/Esters
[0127] The agents of the present invention can be present as salts
or esters, in particular pharmaceutically acceptable salts or
esters.
[0128] Pharmaceutically acceptable salts of the agents of the
invention include suitable acid addition or base salts thereof. A
review of suitable pharmaceutical salts may be found in Berge et
al, J Pharm Sci, 66, 1-19 (1977). Salts are formed, for example
with strong inorganic acids such as mineral acids, e.g. sulphuric
acid, phosphoric acid or hydrohalic acids; with strong organic
carboxylic acids, such as alkanecarboxylic acids of 1 to 4 carbon
atoms which are unsubstituted or substituted (e.g., by halogen),
such as acetic acid; with saturated or unsaturated dicarboxylic
acids, for example oxalic, malonic, succinic, maleic, fumaric,
phthalic or tetraphthalic; with hydroxycarboxylic acids, for
example ascorbic, glycolic, lactic, malic, tartaric or citric acid;
with aminoacids, for example aspartic or glutamic acid; with
benzoic acid; or with organic sulfonic acids, such as
(C.sub.1-C.sub.4)-alkyl- or aryl-sulfonic acids which are
unsubstituted or substituted (for example, by a halogen) such as
methane- or p-toluene sulfonic acid.
[0129] Esters are formed either using organic acids or
alcohols/hydroxides, depending on the functional group being
esterified. Organic acids include carboxylic acids, such as
alkanecarboxylic acids of 1 to 12 carbon atoms which are
unsubstituted or substituted (e.g., by halogen), such as acetic
acid; with saturated or unsaturated dicarboxylic acid, for example
oxalic, malonic, succinic, maleic, fumaric, phthalic or
tetraphthalic; with hydroxycarboxylic acids, for example ascorbic,
glycolic, lactic, malic, tartaric or citric acid; with aminoacids,
for example aspartic or glutamic acid; with benzoic acid; or with
organic sulfonic acids, such as (C.sub.1-C.sub.4)-alkyl- or
aryl-sulfonic acids which are unsubstituted or substituted (for
example, by a halogen) such as methane- or p-toluene sulfonic acid.
Suitable hydroxides include inorganic hydroxides, such as sodium
hydroxide, potassium hydroxide, calcium hydroxide, aluminium
hydroxide. Alcohols include alkanealcohols of 1-12 carbon atoms
which may be unsubstituted or substituted, e.g. by a halogen).
Enantiomers/Tautomers
[0130] The invention also includes where appropriate all
enantiomers and tautomers of the agents. The man skilled in the art
will recognise compounds that possess an optical properties (one or
more chiral carbon atoms) or tautomeric characteristics. The
corresponding enantiomers and/or tautomers may be isolated/prepared
by methods known in the art.
Stereo and Geometric Isomers
[0131] Some of the agents of the invention may exist as
stereoisomers and/or geometric isomers--e.g. they may possess one
or more asymmetric and/or geometric centres and so may exist in two
or more stereoisomeric and/or geometric forms. The present
invention contemplates the use of all the individual stereoisomers
and geometric isomers of those inhibitor agents, and mixtures
thereof. The terms used in the claims encompass these forms,
provided said forms retain the appropriate functional activity
(though not necessarily to the same degree).
[0132] The present invention also includes all suitable isotopic
variations of the agent or pharmaceutically acceptable salts
thereof. An isotopic variation of an agent of the present invention
or a pharmaceutically acceptable salt thereof is defined as one in
which at least one atom is replaced by an atom having the same
atomic number but an atomic mass different from the atomic mass
usually found in nature. Examples of isotopes that can be
incorporated into the agent and pharmaceutically acceptable salts
thereof include isotopes of hydrogen, carbon, nitrogen, oxygen,
phosphorus, sulphur, fluorine and chlorine such as .sup.2H,
.sup.3H, .sup.13C, .sup.14C, .sup.15N, .sup.17O, .sup.18O,
.sup.31P, 32P, .sup.35S, .sup.18F and .sup.36Cl, respectively.
Certain isotopic variations of the agent and pharmaceutically
acceptable salts thereof, for example, those in which a radioactive
isotope such as .sup.3H or .sup.14O is incorporated, are useful in
drug and/or substrate tissue distribution studies. Tritiated, i.e.,
.sup.3H, and carbon-14, i.e., .sup.14O, isotopes are particularly
preferred for their ease of preparation and detectability. Further,
substitution with isotopes such as deuterium, i.e., .sup.2H, may
afford certain therapeutic advantages resulting from greater
metabolic stability, for example, increased in vivo half-life or
reduced dosage requirements and hence may be preferred in some
circumstances. Isotopic variations of the agent of the present
invention and pharmaceutically acceptable salts thereof of this
invention can generally be prepared by conventional procedures
using appropriate isotopic variations of suitable reagents.
Solvates
[0133] The present invention also includes solvate forms of the
agents of the present invention. The terms used in the claims
encompass these forms.
Polymorphs
[0134] The invention furthermore relates to agents of the present
invention in their various crystalline forms, polymorphic forms and
(an)hydrous forms. It is well established within the pharmaceutical
industry that chemical compounds may be isolated in any of such
forms by slightly varying the method of purification and or
isolation form the solvents used in the synthetic preparation of
such compounds.
Prodrugs
[0135] The invention further includes agents of the present
invention in prodrug form. Such prodrugs are generally compounds
wherein one or more appropriate groups have been modified such that
the modification may be reversed upon administration to a human or
mammalian subject. Such reversion is usually performed by an enzyme
naturally present in such subject, though it is possible for a
second agent to be administered together with such a prodrug in
order to perform the reversion in vivo. Examples of such
modifications include ester (for example, any of those described
above), wherein the reversion may be carried out be an esterase
etc. Other such systems will be well known to those skilled in the
art.
Administration
[0136] The pharmaceutical compositions of the present invention may
be adapted for oral, rectal, vaginal, parenteral, intramuscular,
intraperitoneal, intraarterial, intrathecal, intrabronchial,
subcutaneous, intradermal, intravenous, nasal, buccal or sublingual
routes of administration.
[0137] For oral administration, particular use is made of
compressed tablets, pills, tablets, gellules, drops, and capsules.
Preferably, these compositions contain from 1 to 2000 mg and more
preferably from 50-1000 mg, of active ingredient per dose.
[0138] Other forms of administration comprise solutions or
emulsions which may be injected intravenously, intraarterially,
intrathecally, subcutaneously, intradermally, intraperitoneally or
intramuscularly, and which are prepared from sterile or
sterilisable solutions. The pharmaceutical compositions of the
present invention may also be in form of suppositories, pessaries,
suspensions, emulsions, lotions, ointments, creams, gels, sprays,
solutions or dusting powders.
[0139] An alternative means of transdermal administration is by use
of a skin patch. For example, the active ingredient can be
incorporated into a cream consisting of an aqueous emulsion of
polyethylene glycols or liquid paraffin. The active ingredient can
also be incorporated, at a concentration of between 1 and 10% by
weight, into an ointment consisting of a white wax or white soft
paraffin base together with such stabilisers and preservatives as
may be required.
[0140] Injectable forms may contain between 10-1000 mg, preferably
between 10-500 mg, of active ingredient per dose.
[0141] Compositions may be formulated in unit dosage form, i.e., in
the form of discrete portions containing a unit dose, or a multiple
or sub-unit of a unit dose.
[0142] In a particularly preferred embodiment, the combination or
pharmaceutical composition of the invention is administered
intravenously.
Dosage
[0143] A person of ordinary skill in the art can easily determine
an appropriate dose of one of the instant compositions to
administer to a subject without undue experimentation. Typically, a
physician will determine the actual dosage which will be most
suitable for an individual patient and it will depend on a variety
of factors including the activity of the specific compound
employed, the metabolic stability and length of action of that
compound, the age, body weight, general health, sex, diet, mode and
time of administration, rate of excretion, drug combination, the
severity of the particular condition, and the individual undergoing
therapy. The dosages disclosed herein are exemplary of the average
case. There can of course be individual instances where higher or
lower dosage ranges are merited, and such are within the scope of
this invention.
[0144] Depending upon the need, the agent may be administered at a
dose of from 0.1 to 30 mg/kg body weight, such as from 2 to 20
mg/kg, more preferably from 0.1 to 1 mg/kg body weight.
[0145] By way of guidance,
1-(2-C-cyano-2-dioxy-.beta.-D-arabino-pentofuranosyl)-N4-palmitoyl
cytosine is typically administered in accordance with a physician's
direction at total dosages of between 100 mg and 800 mg per day.
Preferably, the dose is administered orally. The doses can be given
5 days a week for 4 weeks, or 3 days a week for 4 weeks. Dosages
and frequency of application are typically adapted to the general
medical condition of the patient and to the severity of the adverse
effects caused, in particular to those caused to the hematopoietic,
hepatic and to the renal system. The total daily dose can be
administered as a single dose or divided into separate dosages
administered two, three or four time a day.
[0146] The DNA methyltransferase inhibitor decitabine
(Dacogen.RTM.) is typically administered subcutaneously or
intravenously in accordance with a physician's direction. By way of
guidance, the recommended decitabine dose is 15 mg/m.sup.2
administered by continuous intravenous infusion over 3 h repeated
every 8 h for 3 days (decitabine clinical label; Fenaux P. (2005)
Nature Clinical Practice, 2, S36-44). This cycle is preferably
repeated every 6 weeks. Patients with advanced solid tumours
typically receive a 72 h infusion of decitabine at 20-30
mg/m.sup.2/day.
[0147] Alternatively, decitabine may be administered at a dose of
20 mg/m.sup.2 by continuous intravenous infusion over 1 hour
repeated daily for 5 days. The cycle is repeated every 4 weeks (see
FDA approved drug label for decitabine).
[0148] The present invention is further described by way of
example, and with reference the Figures.
Examples
Materials & Methods
Cell Lines and Reagents
[0149] MV4-11, HL60 and CEM cells were purchased from the ECACC
(Salisbury, UK) ATCC. Cells were cultured at 37.degree. C. with 5%
CO2 in RPMI 1640 media containing 10% fetal calf serum (FCS). Cells
were kept at a density of between 0.2.times.10.sup.6 and
1.times.10.sup.6 cells/ml.
[0150] CNDAC was prepared in accordance with the methodology set
forth in EP 535231B (Sankyo Company Limited). CYC682 (sapacitabine)
was prepared in accordance with the methodology described in EP
536936B (Sankyo Company Limited). Decacitabine and Azacitidine were
purchased from Sigma-Aldrich. Stock solutions of all compounds were
prepared in dimethyl sulphoxide (DMSO) at 10 mM. All reagents were
purchased from Sigma (Poole, UK) unless stated otherwise.
Cell Culture/Cytotoxicity Assays
[0151] In order to complete the combination studies, the cytotoxic
effects of individual compounds were determined. To establish the
72 hour IC.sub.50 for each compound, experiments were carried out
in 96-well plates and the cell lines seeded at a density of
5,000/well for MV4-11 and HL60 cells and 6,000/well for CCRF-CEM
cells. In each cell line, 72 h treatment IC.sub.50 values were
determined for each compound using the alamar blue assay.
[0152] A dilution series for each drug was prepared in medium. Two
hours after seeding, an equal volume of each compound was added at
twice the desired concentration and incubated for 72 hours. All
treatments were performed in triplicate. At the end of the
incubation, a 20% stock of alamar blue (Roche, Lewes, UK) was
prepared in media, and an equal volume was added to each well and
incubated for three hours. Absorbance was read at 544-595 nm and
data was analysed (Excel Fit v4.0) to determine the IC.sub.50
(concentration of compound that inhibited cell growth by 50%) for
each compound.
[0153] CNDAC was then tested in combination with decitabine or
azacitidine using three different treatment regimes: concomitant,
CNDAC pre-treatment followed by methyltransferase inhibitor, and
methyltransferase inhibitor pretreatment followed by CNDAC.
Calcusyn Drug Combination Protocol
[0154] Combination treatments were evaluated as follows: a
cytotoxicity assay was used treating cells with two drugs at a
range of concentrations and analysed using the median effect model
(Chou and Talalay, 1984). For the cytotoxicity assays, treatments
were either concomitant (e.g. nucleoside analogue+DMTi) or 24 hours
pre-treatment of nucleoside analogue followed by 72 hours with
concomitant treatment of both agents (nucleoside analogue--DMTi)
and vice versa (DMTi--nucleoside analogue). Purely sequential
treatments were not possible to perform with suspension cell lines.
The dosing used was based around the IC.sub.50 for 72 hours.
[0155] Since MV4-11, HL60 and CCRF-CEM cells do not adhere to
96-well plates, it was not practical to aspirate the medium from
the wells, so the pre-treatment compounds were not removed during
the combination experiments. For the combination analysis, 2-fold
serial dilutions of each compound were used, with the concentration
range of the single agents chosen so that it spanned the IC.sub.50
value of the compound. CNDAC, decitabine and azacitidine were
dissolved in DMSO prior to adding compound to media.
[0156] For the concomitant treatment, serial dilutions of CNDAC,
methyltransferase inhibitor, or both drugs simultaneously were
added to cells 24 h after plating, and left for 72 h at 37.degree.
C. In the pre-treatment regimes, the first drug was added
immediately after cells were plated, and left for 24 h. Fresh
medium containing the second drug was then added, and incubated for
72 h. The two controls for each sequential treatment involved
substituting one of the drug treatments with medium. All treatments
were performed in triplicate.
[0157] After drug treatment, the cell number in each well was then
estimated by incubating the cells for approximately 6 h in medium
containing 10% alamar blue (Roche, Lewes, East Sussex, U.K.) and
reading the absorbance at 544-595 nm. Drug interactions were
analysed using the commercial software package Calcusyn, which is
based on the median effect model of Chou and Talalay (Chou, T. C.
& Talalay, P. (1984) Adv. Enzyme Regul. 22, 27-55. Quantatative
analysis of dose-effect relationships: the combined effects of
multiple drugs or enzyme inhibitors). A Combination Index (C.I.) of
1 indicated an additive drug interaction, whereas a C.I. greater
than 1 was antagonistic and a score lower than 1 was synergistic.
The CI value definitions are as follows: 1.45-1.2 is moderately
antagonistic, 1.2-1.1 is slightly antagonistic, 1.1-0.9 is
additive, 0.9-0.85 is slightly synergistic, 0.85-0.7 is moderately
synergistic and 0.7-0.3 is synergistic.
Cell Cycle Analysis
[0158] Cell treatments were as follows: for single agent
evaluation, HL60 cells were seeded in triplicate at 0.3.times.106
cells/ml in medium and were treated with 128 nM
(0.5.times.IC.sub.50) azacitidine or 133 nM (lx IC.sub.50) CNDAC or
DMSO only for 48 or 72 hours before harvesting for flow cytometry.
For combination analysis, cells were treated with azacitidine for
24 hours followed by a further 48 or 72 hours with azacitidine and
CNDAC. For controls, single agent treatments for each drug were
also performed. At the end of the incubation, cells were harvested
by washing twice in PBS and fixation in 70% ethanol and storage at
-20.degree. C. Prior to analysis cells were washed twice in PBS
containing 1% BSA followed by staining with propidium iodide (50
.mu.g/ml) and ribonuclease A (50 .mu.g/ml) in PBS containing 0.1%
Triton X-1 00 and the cell cycle profile was determined by flow
cytometry.
Annexin V Staining
[0159] HL60 cells were pre-treated with 128 nM azacitidine
(equivalent to 0.5.times.IC.sub.50) for 24 hours followed by
concomitant treatment with 128 nM azacitidine and 133 nM CNDAC
(equivalent to 1.times.IC.sub.50) for 48 or 72 hours. Single agent
treatments were also performed as controls. After incubation cells
were centrifuged at 500 g for 5 min, washed twice in PBS and once
in annexin buffer (10 mM Hepes pH 7.4, 2.5 mM CaCl.sub.2), and 140
mM NaCl). Cells were resuspended at 1.times.10.sup.6/ml and 100
.mu.l was transferred to a 5 ml tube prior to incubation for 10 min
in the dark at room temperature with 5 .mu.l of annexin V-FITC
stain (Beckton Dickinson) and 10 .mu.l of propidium iodide [50
mg/ml]. Annexin buffer (1 ml) was added and the cells were analysed
by flow cytometry. Annexin V positive cells (apoptotic) were
designated on the basis of green fluorescence and propidium iodide
(dead) positive cells were designated on the basis of red
fluorescence.
Preparation and Analysis of Cell Lysates by Immunoblotting
[0160] Cells were seeded at 0.3.times.10.sup.6 cells/ml in T25
flasks and treated with either DMSO, or azacitidine at 128 nM
(equivalent to 0.5.times.IC.sub.50) for 24 hours followed by
concomitant treatment with 128 nM azacitidine and 133 nM CNDAC
(equivalent to 1.times.IC.sub.50) for a further 24, 36, 40, 48 and
72 hours.
[0161] Cells were harvested by centrifugation at 500 g for 5 min,
washed once with ice-cold PBS and resuspended in 100 .mu.l of lysis
buffer (50 mM HEPES, pH 7.0, 20 mM NaCl, 1 mM DTT, lx protease
inhibitors, 10 mM sodium pyrophosphate, 10 mM NaF and 1 mM
Na.sub.3VO.sub.4). All samples were lysed by sonication (2.times.3s
bursts using Sanyo soniprep 150 at 5 amp setting). The protein
concentration of each lysate was determined using the BCA assay
(Perbio Science, Northumberland, U.K.).
[0162] Lysate (30 .mu.g) was mixed with gel loading buffer
containing reducing agent and separated on 10% or 12%
polyacrylamide gels using denaturing electrophoretic conditions
according to manufacturers instructions (Invitrogen, Glasgow, UK).
Proteins were transferred to nitrocellulose membranes (Hybond ECL,
Amersham, Chalfont St.Giles, UK) using wet electrophoretic
transfer. Membranes were stained with ponceau S to confirm equal
loading before blocking in 5% non-fat milk in PBS with 0.1% Tween
20 (PBSTM) for 1 hour. Membranes were incubated overnight at
4.degree. C. with primary antibody, diluted in PBSTM. Antibodies
used in this study were: cleaved PARP (Becton Dickinson). Membranes
were washed in PBS and 0.1% Tween 20 (PBST) and incubated for 1
hour in PBSTM containing horseradish peroxidase-conjugated
secondary antibody. Membranes were washed and incubated with ECL
solution (Amersham) and exposed to X-ray film (Amersham).
Results
CNDAC and Decitabine in Combination in Haematological Cell
Lines
[0163] CNDAC was tested in combination with decitabine in the AML
cell lines HL60 and MV4-11, and the ALL cell line CCRF-CEM using
three different treatment regimes. The Combination Index values
from each drug treatment are shown for ED50, ED75 and ED90 values
in Table 1 (the point on the curve where 50%, 75% and 90% of the
cells have been killed). Data are the average of three independent
experiments.
TABLE-US-00001 TABLE 1 CNDAC Decitabine Cell Line Effect
pretreatment pretreatment Concomitant MV4-11 ED50 0.95 1.17 0.79 (n
= 3) ED75 0.71 0.66 0.88 ED90 0.59 0.44 1.06 HL60 ED50 1.16 0.6
1.47 (n = 3) ED75 0.64 0.48 1.1 ED90 0.68 0.62 1.86 CCRF- ED50 0.58
0.94 1.29 CEM ED75 0.5 0.68 0.85 (n = 3) ED90 0.64 0.52 0.85
[0164] CNDAC and decitabine generated moderate to strong synergy in
all three cell lines tested. CNDAC pre-treatment and decitabine
pretreatment were both particularly effective treatment regimes for
this combination. These results support the idea of combining CNDAC
with decitabine in haematological cell lines.
CNDAC and Azacitidine in Combination in Haematological Cell
Lines
[0165] CNDAC was tested in combination with azacitidine in the AML
cell lines HL60 and MV4-11, and the ALL cell line CCRF-CEM using
three different treatment regimes. The Combination Index values
from each drug treatment are shown for ED50, ED75 and ED90 values
in Table 2 (the point on the curve where 50%, 75% and 90% of the
cells have been killed). Data are the average of three independent
experiments.
TABLE-US-00002 TABLE 2 CNDAC Azacitidine Cell Line Effect
pretreatment pretreatment Concomitant MV4-11 ED50 1.23 1.09 1.13 (n
= 3) ED75 0.95 1.04 1.03 ED90 0.77 1.02 0.96 HL60 ED50 1.33 0.91
1.24 (n = 3) ED75 1.13 0.6 1.11 ED90 1.03 0.4 0.99 CCRF- ED50 0.75
0.76 1.02 CEM ED75 0.71 0.61 1.09 (n = 3) ED90 0.72 0.51 1.19
[0166] CNDAC and azacitidine induced moderate to strong synergy in
all three cell lines tested. Azacitidine pretreatment generated
strong synergy in HL60 and CEM cells, whereas CNDAC pre-treatment
produced moderate synergy in MV4-11 and CEM cells. These results
support the idea of combining CNDAC with azacitidine in
haematological cell lines.
Cell Cycle Analysis
[0167] HL-60 or MV4-11 cells were treated with DMSO, CNDAC or
azacitidine, as indicated in FIGS. 1A and 2A. The compound
concentrations evaluated were HL-60 cells azacitidine
0.5.times.IC.sub.50=0.13 .mu.M; CNDAC IC.sub.50=0.13 .mu.M: MV4-11
cells CNDAC IC.sub.50=0.46 .mu.M. The cell cycle profiles were
analysed after treatment under the indicated conditions.
[0168] Treatment with azacitidine alone caused an accumulation of
cells in sub-G1, G2/M, and >G2/M seen at both 72 and 96 hours
exposure (FIGS. 1A and 2A). CNDAC treatment alone caused an
accumulation of cells in G2/M by 48 hours with a small induction of
cells in sub-G1. The combination of agents showed a small
additional increase in cells in sub-G1 with little change in the
other cell cycle phases by 48 hours. By 72 hours, a more dramatic
increase in sub-G1 representing 45% of the cells compared to 9% and
7% for the azacitidine and CNDAC single agent treatments
respectively. Taken together these data suggest that the
combination treatment causes a time dependent increase in cell
death greater than either agent alone.
Annexin V Analysis
[0169] To evaluate the cell death in more detail, single agent and
combination treatments of azacitidine and CNDAC in HL60s were
measured by annexin V, a marker of apoptosis. Cells were exposed to
azacitidine (128 nM) for a total of 96 hours. For the combination
treatment after 24 hours, CNDAC (133 nM) was added for a further 72
hours in the presence of azacitidine. Single agent treatment with
azacitidine caused a small increase in the proportion of apoptotic
cells by 72 and 96 hours (FIGS. 1B and 2B). CNDAC alone showed
little effect at either 48 or 72 hours compared to controls (FIGS.
1B and 2B). The combination of agents showed greater effects (66%)
than either agent alone (azacitidine: 30.5% and CNDAC: 16.5%) with
the greatest difference between single agents and the combination
at the longest time point of 96 hours total treatment (FIG.
2B).
Western Blot Experiments
[0170] In order to complement the cell cycle analysis, HL60 cells
treated with the single agents or with the combination were
assessed for induction of cleaved PARP (a marker of apoptosis) at a
range of time points (FIG. 3).
[0171] HL-60 cells were treated with DMSO, 0.13 .mu.M azacitidine,
0.13 .mu.M CNDAC or both agents (AC). The schedule involved 24 h
azacitidine or DMSO pretreatment followed by the addition of CNDAC
or DMSO for the indicated times. Cells were harvested after 48 h-96
h total treatment time. The resulting lysates (20 .mu.g) were
resolved on 12% acrylamide Bis-Tris gels, transferred to
nitrocellulose membranes and probed with the antibodies shown in
FIG. 3. Results showed that treatment with azacitidine alone caused
a small induction in cleaved PARP at early time points. Cleaved
PARP was also seen in the combination treatment. At later time
points, CNDAC also induced cleaved PARP at later time points.
Treatment with the combination showed greater effects on cleaved
PARP than either agent alone. The results indicate that the CNDAC
and azacitidine combination induces apoptosis but does not modulate
Bcl-2 family proteins.
Dosing Schedule for AML
[0172] In AML cell lines, the active metabolite of sapacitabine,
CNDAC, is synergistic with hypomethylating agents and the synergy
is more apparent if cells are treated with hypomethylating agents
first.
[0173] A phase 1/2 study was carried out in order to evaluate the
safety and efficacy of administering sapacitabine in alternating
cycles with decitabine in newly diagnosed elderly AML. The
decitabine dose is 20 mg/m.sup.2 infused intravenously/day.times.5
consecutive days followed by 3-week rest for the first and odd
number of cycles; the sapacitabine dose is 300 mg b.i.d..times.3
days/week.times.2 weeks followed by 2-week rest for the second and
even number of cycles. These doses are considered tolerable if DLT
occurs in .ltoreq.2 of 6 patients in the Phase 1 part. The sample
size for Phase 2 is 24 patients including those who have received
the same doses of both drugs in the Phase 1 part because
eligibility criteria are the same for both parts. The primary
efficacy endpoint is response rate (CR, CRp, PR, or major HI). A
secondary efficacy endpoint is median overall survival. The regimen
will be considered tolerable if dose-limiting toxicity occurs in
less than 33% of patients and the 8-week mortality is less than
37%. Eight-week mortality, or death rate, is defined as death due
to any cause occurring within 60 days after the date of patient
registration into the study.
Methods:
[0174] Eligible patients must be .gtoreq.70 years with AML
previously untreated for whom the treatment of choice is
low-intensity therapy or the patient has refused standard induction
chemotherapy; patients who received hypomethylating agents for
prior MDS or MPD are excluded.
Results:
[0175] 25 patients were treated with the above doses of decitabine
and sapacitabine and 16 had .gtoreq.60 days of follow-up. Median
age is 76. No dose-limiting toxicities were observed and the 8-week
mortality rate was 12.0%. The response rate (CR, CRp, PR, or major
HI) was 40%. Three patients achieved CR and 2 patients achieved PR
and 1 patient achieved major HI in platelets. Time to response is
2-4 cycles. Eight patients have received 4 cycles of treatment.
Three patients died within 60-days and the deaths were unrelated to
study drugs by investigator assessment. Common adverse events
(regardless of causality) included weakness, anorexia, nausea,
diarrhoea, dehydration, dyspnea, edema, pneumonia, febrile
neutropenia, neutropenia, thrombocytopenia, anemia, and
hypocalcemia, most of which were moderate in intensity. These
interim data suggest that this treatment regimen is safe and active
in elderly AML.
[0176] Among a further 21 patients treated in a separate clinical
study with an identical regimen and at least 60 days of follow-up,
the rate of dose-limiting toxicity was 9.5% and the 8-week
mortality rate was 14.3%. As above, the patients received
intravenous decitabine at 20 mg/m.sup.2 per day for five
consecutive days of a 4-week cycle (odd cycles) and sequentially
sapacitabine at 300 mg orally twice per day for three days per week
for two weeks of a 4-week cycle (even cycles).
[0177] The 30-day death rate across all 46 patients treated with
the regimen was 5%.
[0178] Various modifications and variations of the invention will
be apparent to those skilled in the art without departing from the
scope and spirit of the invention. Although the invention has been
described in connection with specific preferred embodiments, it
should be understood that the invention as claimed should not be
unduly limited to such specific embodiments. Indeed, various
modifications of the described modes for carrying out the invention
which are obvious to those skilled in the relevant fields are
intended to be covered by the present invention.
* * * * *