EA043592B1 - ANTI-PROLIFERATIVE COMPOUNDS AND BISPECIFIC ANTIBODIES TO BCMA AND CD3 FOR COMBINED USE - Google Patents

Description

This application claims priority to U.S. Provisional Application No. 62/675,639, filed May 2018, which is incorporated herein by reference in its entirety.

This application contains a sequence listing, which is provided electronically under the file name 10624-451-228_SeqListing.txt, created on May 21, 2019 and has a size of 70646 bytes.

The sequence listing is incorporated herein by reference in its entirety.

1. Technical field

Proposed herein are methods of using 4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1oxoisoindolin-4-yl)oxy)methyl)benzyl)piperazin-1-yl)- 3-fluorobenzonitrile, or an enantiomer thereof, a mixture of enantiomers, a tautomer or a pharmaceutically acceptable salt in combination with a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3), for the treatment, prevention or control of multiple myeloma .

2. State of the art

Multiple myeloma (MM) is a cancer of plasma cells in the bone marrow. Typically, plasma cells produce antibodies and play a key role in the functioning of the immune system. However, uncontrolled growth of these cells leads to bone fractures and bone pain, anemia, infection and other complications. Multiple myeloma is the second most common hematologic malignancy, although the exact causes of multiple myeloma remain unknown. Multiple myeloma causes high levels of proteins in the blood, urine, and organs, including, but not limited to, M protein and other immunoglobulins (antibodies), albumin, and beta-2 microglobulin, except in some patients (estimated at 1 to 5 %) whose myeloma cells do not secrete these proteins (so-called non-secretory myeloma). M protein, short for monoclonal protein, also known as paraprotein, is a particularly abnormal protein produced by myeloma plasma cells and can be found in the blood or urine of almost all patients with multiple myeloma, except patients who have nonsecretory myeloma, or whose myeloma cells produce heavy chain immunoglobulin light chains.

Skeletal symptoms, including bone pain, are among the most clinically significant symptoms of multiple myeloma. Malignant plasma cells release osteoclast-stimulating factors (including IL-1, IL-6, and TNF), which cause calcium to be leached from bone, causing lytic lesions; Another symptom is hypercalcemia. Osteoclast-stimulating factors, also called cytokines, can prevent apoptosis or death of myeloma cells. Fifty percent of patients have radiographically detectable skeletal lesions associated with myeloma at the time of diagnosis. Other common clinical symptoms of multiple myeloma include polyneuropathy, anemia, hyperviscosity, infections and renal failure.

Current treatment for multiple myeloma may involve one or more of surgery, stem cell transplant, chemotherapy, immunotherapy, and/or radiation therapy to destroy multiple myeloma cells in a patient. All modern therapeutic approaches have significant disadvantages for the patient.

In the last decade, new therapeutic agents, particularly immunomodulatory drugs such as lenalidomide and pomalidomide, have significantly improved response rates, prolonged progression-free survival (PFS), and overall survival (OS) in patients with multiple myeloma. However, persistent levels of residual disease that are below the sensitivity of bone marrow (BM) morphology, protein immunofixation electrophoresis, and light chain quantitation exist in many patients with multiple myeloma, even after these patients have achieved a complete response (CR). , and ultimately cause relapse of the disease. Minimal residual disease (MRD) in myeloma is an independent prognostic factor for progression-free survival (PFS) and is being considered as a surrogate trial endpoint to improve the identification of effective treatments, particularly for front-line trials that currently require 5 to 10 years follow-up to determine differences in survival. Monitoring minimal residual disease (MRD) in patients with multiple myeloma thus provides prognostic value in predicting PFS and OS and guiding treatment decisions. When defining minimal residual disease (MRD) in myeloma, a threshold of 0.01% (10 ^-4 ) after treatment can be used, that is, a proportion of 10 ^-4 or less multiple myeloma cells of the total number of mononuclear cells in the bone marrow is considered MRD negative, and a proportion of 10 ^-4 cells or more are MRD positive. The 10 ^-4 MRD threshold was originally based on technical feasibility, but quantification of MRD is now possible at 10 ^-5 using flow cytometry and 10 ^-6 using high-throughput sequencing. (Rawstron et al, Blood 2015;125(12): 1932-1935). Methods for measuring MRD include VDJ DNA sequencing, polymerase chain reaction (PCR) (including allele-specific PCR, ASO PCR), and multiparameter flow cytometry (MPC). MRD assays, for example based on clonotype profile measurements, are also described in US Pat. No. 8,628,927 to Faham et al., which is incorporated herein by reference.

There is a significant need for safe and effective compounds and methods for treating, preventing and controlling multiple myeloma, including for patients whose multiple myeloma is newly diagnosed or refractory to standard treatments, while reducing or avoiding toxicity and/or side effects. associated with traditional therapy.

The citation or identification of any reference in Section 2 of this application should not be construed as an admission that such reference predates the prior art of this application.

In general, the technical description of one embodiment proposed herein may be combined with that disclosed in any other embodiments presented herein.

3. Essence of the invention

Proposed herein are methods of using 4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1oxoisoindolin-4-yl)oxy)methyl)benzyl)piperazin-1-yl)- 3-fluorobenzonitrile, or an enantiomer thereof, a mixture of enantiomers, a tautomer or a pharmaceutically acceptable salt in combination with a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and to human CD3s (CD3), for the treatment, prevention or control of multiple myeloma .

In one such embodiment, the compound for use in the compositions and methods provided herein is 4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1oxoisoindolin-4-yl )oxy)methyl)benzyl)piperazin-1-yl)-3-fluorobenzonitrile (Compound 1):

or an enantiomer, mixture of enantiomers, tautomer, isotopologue or pharmaceutically acceptable salt thereof.

In another embodiment, the compound for use in the compositions and methods provided herein is (S)-4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1oxoisoindolin- 4-yl)oxy)methyl)benzyl)piperazin-1-yl)-3-fluorobenzonitrile (Compound 2):

or a tautomer, isotopologue or pharmaceutically acceptable salt thereof.

In yet another embodiment, the compound for use in the compositions and methods provided herein is (K)-4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1oxoisoindolin- 4-yl)oxy)methyl)benzyl)piperazin-1-yl)-3-fluorobenzonitrile (Compound 3):

or a tautomer, isotopologue or pharmaceutically acceptable salt thereof.

In one embodiment, the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region with SEQ ID NO: 21, a CDR2H region with SEQ ID NO: 22 and a CDR3H region with SEQ ID NO: 17, and a VL region containing a CDR3L region with SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

Also provided for use in the methods disclosed herein are pharmaceutical compositions formulated for administration by appropriate route and means, containing effective concentrations of the compounds provided herein, for example, Compound 1, Compound 2 or Compound 3, or an enantiomer thereof, a mixture of enantiomers , tautomer, isotopologue or pharma

- 2 043592 of a cetically acceptable salt, and optionally containing at least one pharmaceutical carrier. Also provided for use in the methods disclosed herein are pharmaceutical compositions formulated for administration by a suitable route and means containing effective concentrations of the antibodies provided herein, for example, a bispecific antibody comprising a first binding moiety that specifically binds to a B-maturation antigen. human cells (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22, and a CDR3H region with SEQ ID NO: 17, and a VL region comprising a CDR3L region with SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, the pharmaceutical compositions deliver amounts effective to treat multiple myeloma. In one embodiment, the pharmaceutical compositions deliver amounts effective for the prevention of multiple myeloma. In one embodiment, the pharmaceutical compositions deliver amounts effective to alleviate multiple myeloma.

Also provided herein are combination therapies using compounds or compositions provided herein, or enantiomers, mixtures of enantiomers, tautomers, isotopologues, or pharmaceutically acceptable salts thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and with human CD3ε (CD3) as provided herein, in combination with another therapy, for example, another pharmaceutical agent with activity against multiple myeloma or its symptoms. Examples of therapies within the scope of these methods include, but are not limited to, surgery, chemotherapy, radiation therapy, biological therapy, stem cell transplantation, cell therapy, and combinations thereof.

The compounds or compositions provided herein, or pharmaceutically acceptable derivatives thereof, may be administered concomitantly with, before, or after the administration of any other and one or more of the above therapeutic agents. Also provided are pharmaceutical compositions containing a compound provided herein and one or more of the above therapies.

In the methods, an effective amount of compounds or compositions containing therapeutically effective concentrations of the compounds is administered to an individual exhibiting symptoms of multiple myeloma to be treated. These amounts are effective in relieving or eliminating one or more symptoms of multiple myeloma.

Additionally also provided is a pharmaceutical kit or kit containing one or more containers filled with one or more ingredients of pharmaceutical compositions. If necessary, notice may be provided associated with such container(s) in a form prescribed by the government agency regulating the manufacture, use, or sale of pharmaceuticals or biological products that reflects the agency's approved manufacture, use, or sale for human administration. The package or kit may be labeled with information about the route of administration, the sequence of administration of the drug (eg, separately, sequentially or simultaneously), or the like.

These and other aspects of the subject matter described herein will become apparent with reference to the following detailed description.

4. Detailed description of the invention

A. Definitions

Unless otherwise specified, all technical and scientific terms used herein have the same meaning as commonly understood by one skilled in the art. All patents, applications, published applications and other publications are incorporated by reference in their entirety. If there are multiple definitions of a term mentioned in this document, the definition provided in this section should be used unless otherwise noted.

The use of the singular term when used in conjunction with the term containing in claims and/or specifications can mean one, but it also means one or more, at least one and one or more than one.

As used herein, the terms containing and including may be used interchangeably. The terms containing and including should be interpreted to indicate the presence of specified features or components as specified, but do not exclude the presence or addition of one or more features or components, or groups thereof. Additionally, the terms containing and including are intended to include examples covered by the term consisting of. Therefore, the term consisting of may be used in place of the terms containing and including to provide more specific embodiments of the invention.

The term consisting of means that an item has at least 90%, 95%, 97%, 98%, or 99% of the stated features or components of which it is composed. In another embodiment of the invention, the term consisting of excludes from the scope of any subsequent listing any other features or components other than those that are not essential to the technical effect to be achieved.

As used herein, the term or should be interpreted to include or to mean any one or any combination. Therefore, A, B or C means any of the following: A; IN; WITH; A and B; A and C; B and C; A, B and C. An exception to this definition will only occur if the combination of elements, functions, steps or activities is in some way mutually exclusive.

IC ₅₀ refers to the amount, concentration or dose of a particular test compound that achieves 50% inhibition of the maximum response, such as receptor binding, receptor activity, cell growth or proliferation, as measured by any of the in vitro assays or cell-based assays described in this document.

Pharmaceutically acceptable salts include, without limitation, amine salts such as, but not limited to, N,N'-dibenzylethylenediamine, chloroprocaine, choline, ammonia, diethanolamine and other hydroxyalkylamines, ethylenediamine, N-methylglucamine, procaine, N-benzylphenethylamine, 1 -parachlorobenzyl-2-pyrrolidin-1'-ylmethyl-benzimidazole, diethylamine and other alkylamines, piperazine and tris(hydroxymethyl)aminomethane; alkali metal salts such as, but not limited to, lithium, potassium and sodium; alkaline earth metal salts such as, but not limited to, barium, calcium and magnesium; transition metal salts such as, but not limited to, zinc; and salts of other metals such as, but not limited to, sodium hydrogen phosphate and disodium phosphate; and also include, but are not limited to, salts of mineral acids such as, but not limited to, hydrochlorides and sulfates; and salts of organic acids such as, but not limited to, acetates, lactates, malates, tartrates, citrates, ascorbates, succinates, butyrates, valerates, fumarates and organic sulfonates.

Unless specifically stated otherwise, when a compound can be expected to have alternative tautomeric, regioisomeric and/or stereoisomeric forms, all alternative isomers are embraced within the scope of the claimed subject matter. For example, where a compound may have one of two tautomeric forms, it is intended that both tautomers be included herein.

Thus, the compounds provided herein may be enantiomerically pure or be stereoisomeric or diastereomeric mixtures. As used herein and unless otherwise indicated, the term stereomerically pure or optically pure means a composition that contains one stereoisomer of a compound and substantially no other stereoisomers of the compound. For example, a stereomerically pure composition of a compound having a single chiral center will be substantially free of the opposite enantiomer of the compound. A stereopure composition of a compound having two chiral centers will be substantially free of other diastereomers of the compound. A typical stereoisomerically pure compound contains more than about 80% by weight of one stereoisomer of the compound and less than about 20% by weight of the other stereoisomers of the compound, in one embodiment, more than about 90% by weight of one stereoisomer of the compound and less than about 10 % by weight of other stereoisomers of a given compound, in one embodiment, more than about 95% by weight of one stereoisomer of a given compound and less than about 5% by weight of other stereoisomers of a given compound, and in one embodiment, more than about 97% by weight one stereoisomer of a given compound and less than about 3% by weight of other stereoisomers of a given compound. As used herein, a stereomerically pure compound contains more than about 80% by weight of one stereoisomer of the compound, in one embodiment, more than about 90% by weight of one stereoisomer of the compound, in one embodiment, more than about 95% by weight by weight of one stereoisomer of the compound, and in one embodiment, more than about 97% by weight of one stereoisomer of the compound. As used herein and unless otherwise indicated, the term stereomerically enriched means a composition that contains more than about 60% by weight of one stereoisomer of a compound, in one embodiment, more than about 70% by weight, and in one embodiment, more than about 80% by weight of one stereoisomer of the compound. As used herein and unless otherwise indicated, the term enantiomerically pure means a stereomerically pure composition of a compound having a single chiral center. Likewise, the term stereomerically enriched means a stereomerically enriched composition of a compound having a single chiral center. As used herein, mixtures of stereoisomers or diastereomers means a composition that contains more than one stereoisomer of a compound. A typical mixture of stereoisomers of a compound contains about 50% by weight of one stereoisomer of the compound and about 50% by weight of the other stereoisomers of the compound, or contains more than

- 4 043592 about 50% by weight of one stereoisomer of a given compound and less than about 50% by weight of other stereoisomers of a given compound, or contains more than about 45% by weight of one stereoisomer of a given compound and less than about 55% by weight of other stereoisomers of a given compound , or contains more than about 40% by weight of one stereoisomer of the compound and less than about 60% by weight of the other stereoisomers of the compound, or contains more than about 35% by weight of one stereoisomer of the compound and less than about 65% by weight of the others stereoisomers of this compound.

It should be understood that the compounds presented herein may contain chiral centers. Such chiral centers may have either the (R) or (S) configuration, or may be a mixture of both. It should be understood that the chiral centers of the compounds provided herein may undergo epimerization in vivo. Thus, one skilled in the art will appreciate that administering a compound in its (R) form is equivalent, in the case of compounds that undergo epimerization in vivo, to administering the compound in its (S) form.

Optically active (+) and (-), (R)- and (S)-, or (D)- and (L)- isomers can be prepared using chiral synthons or chiral reagents, or separated using conventional methods such as , like chromatography with a chiral stationary phase.

As used herein, isotopologue means an isotopically enriched compound. The term isotopically enriched refers to an atom having an isotopic composition different from the natural isotopic composition of that atom. Isotopically enriched may also refer to a compound containing at least one atom having an isotopic composition different from the natural isotopic composition of that atom. The term isotopic composition refers to the amount of each isotope present for a given atom. Radiolabeled and isotopically enriched compounds are useful as therapeutic agents, for example, therapeutic agents for multiple myeloma, research reagents, for example, binding assay reagents, and diagnostic agents, for example, in vivo imaging agents. All isotopic embodiments of the compounds described herein, whether radioactive or not, are intended to be within the scope of these embodiments proposed herein. In some embodiments, isotopologues of these compounds are provided, for example, the isotopologues of Compound 1, Compound 2, or Compound 3 are compounds enriched in deuterium, carbon-13, or nitrogen-15. In some embodiments, the isotopologues provided herein are deuterium-enriched compounds. In some embodiments, the isotopologues provided herein are deuterium-enriched compounds, where the deuterium enrichment occurs at a chiral center.

In the description given herein, if there is any discrepancy between the chemical name and the chemical formula, the formula takes precedence.

As used herein, the term multiple myeloma refers to hematological conditions characterized by malignant plasma cells and includes the following disorders: monoclonal gammopathy of unknown origin (MGUS); relapsed, refractory or stable multiple myeloma; low-risk, intermediate-risk and high-risk multiple myeloma; newly diagnosed multiple myeloma (including newly diagnosed low-risk, intermediate-risk and high-risk multiple myeloma); multiple myeloma with and without the possibility of transplantation; smoldering (slowly progressive) multiple myeloma (including low-risk, intermediate-risk and high-risk smoldering multiple myeloma); active multiple myeloma; solitary plasmacytoma; extramedullary plasmacytoma; plasma cell leukemia; multiple myeloma of the central nervous system; light chain myeloma; nonsecretory myeloma; immunoglobulin D myeloma; and immunoglobulin E myeloma; and multiple myeloma characterized by genetic abnormalities such as cyclin D translocation (eg, t(11;14)(q13;q32); t(6;14)(p21;32); t(12;14)(p13;q32) ; or t(6;20);); MMSET translocations (e.g. t(4;14)(p16;q32)); MAF translocations (e.g. t(14;16)(q32;q32); t(20;22); t(16; 22)(q11;q13); or t(14;20)(q32;q11)); or other chromosomal factors (eg, deletion 17p13, or chromosome 13; del(17/17p), non-hyperploidy and gain(1q)).

As used herein and unless otherwise noted, the terms treat, treat, and treatment refer to the alleviation or reduction in severity of a symptom associated with the disease or condition being treated, such as multiple myeloma.

The term prevention applies to reducing the symptoms of a specific disease or disorder, such as multiple myeloma. In some embodiments, patients with a family history of multiple myeloma are candidates for preventive regimens. Generally, the term warning refers to administering the drug before the onset of symptoms, especially in patients with possible onset of multiple myeloma.

As used herein and unless otherwise specified, the term containment includes preventing the recurrence of a particular disease or disorder, such as multiple myeloma, in a patient who has suffered from it by prolonging the time that the patient who has suffered from the disease or disorder, remains in remission, reducing patient mortality and/or maintaining reduction in severity or prevention of symptom associated with the disease or condition being controlled.

As used herein, the term subject or patient means an animal, typically a mammal, including a human, such as a human patient.

The term relapse refers to a situation where patients who have had multiple myeloma in remission after therapy have had a return of myeloma cells and a decrease in the number of healthy cells in the bone marrow.

The term refractory or resistant refers to the circumstance when patients, even after intensive treatment, have residual myeloma cells and/or reduced healthy cells in their bone marrow.

As used herein, induction therapy refers to the first treatment for a given disease, or the first treatment provided to induce complete remission of a disease such as cancer. When used alone, induction therapy is considered to be the best treatment available. If residual cancer is found, patients are treated with another therapy called induction therapy. If the patient is in complete remission after induction therapy, additional strengthening and/or maintenance therapy is then provided to prolong remission or potentially cure the patient.

As used herein, the term consolidation therapy refers to treatment of a disease after a first remission has been achieved. For example, consolidation therapy for cancer is treatment provided after the cancer has disappeared after initial therapy. Strengthening therapy may include radiation therapy, a stem cell transplant, or treatment with cancer drugs. Strengthening therapy is also called enhancement therapy and post-remission therapy.

As used herein, the term maintenance therapy refers to the treatment of a disease after remission or best response has been achieved to prevent or delay relapse. Maintenance therapy may include chemotherapy, hormonal therapy, or targeted therapy.

As used herein and unless otherwise indicated, the terms a therapeutically effective amount and an effective amount of a compound refer to an amount sufficient to provide a therapeutic effect in the treatment, prevention and/or control of a disease, such as multiple myeloma, to delay or minimize one or more symptoms associated with the disease or disorder being treated. The terms therapeutically effective amount or effective amount may include an amount that improves overall therapy, reduces or eliminates symptoms or causes of a disease or disorder, or enhances the therapeutic effectiveness of another therapeutic agent.

The terms co-administration and in combination with include the administration of one or more therapeutic agents (eg, a compound provided herein and another anti-multiple myeloma agent, anti-cancer agent or maintenance therapy agent) simultaneously, in parallel or sequentially without any particular limitation on time. In one embodiment, the agents are present in the cell or body of the patient at the same time or exhibit their biological or therapeutic effect at the same time. In one embodiment, the therapeutic agents are in the same composition or in a unit dosage form. In another embodiment, the therapeutic agents are in different compositions or different unit dosage forms.

The term maintenance agent refers to any substance that treats, prevents or controls the adverse effect of treatment with Compound 1, Compound 2 or Compound 3, or an enantiomer or mixture of enantiomers, tautomer, isotopologue or pharmaceutically acceptable salt thereof.

The term biological therapy refers to the administration of biological therapy, such as umbilical cord blood, stem cells, growth factors and the like.

In the context of cancer, inhibition can be assessed by inhibiting disease progression, inhibiting tumor growth, shrinking the primary tumor, alleviating tumor-associated symptoms, inhibiting factors secreted by the tumor, delaying the appearance of primary or secondary tumors, delaying the development of primary or secondary tumors, reducing the occurrence of primary or secondary tumors, slowing or reducing the severity of secondary effects of the disease, delaying tumor growth and regression of tumors, increasing time to progression (TTP), increasing progression-free survival (PFS), increasing overall survival (OS), among others. As used herein, OS refers to the time from the start of treatment to death from any cause. As used herein, TLT refers to the time from initiation of treatment to tumor progression; The VDP does not include deaths. In one embodiment, PFS means the time from the start of treatment to tumor progression or death. In one embodiment, PFS means the time from the first dose of a compound to the first occurrence of disease progression.

- 6 043592 death or death from any cause. In one embodiment, PFS rates will be calculated using Kaplan-Meier estimates. Event-free survival (EFS) refers to the time from the start of treatment until any occurrence of treatment failure, including disease progression, treatment interruption for any reason, or death. In one embodiment, overall response rate (ORR) means the proportion of patients who achieve a response to treatment. In one embodiment, ORR means the sum of the proportions of patients who achieve complete and partial responses. In one embodiment, ORR means the proportion of patients whose best response > partial response (PR), according to the IMWG uniform response criteria. In one embodiment, duration of response (DOR) is the time from achievement of response to disease relapse or progression. In one embodiment, the CR is the time from achieving response > partial response (PR) to disease relapse or progression. In one embodiment, the LO is the time from the first documentation of a response to the first documentation of disease progression or death. In one embodiment, the CR is the time from first documentation of response > partial response (PR) to first documentation of disease progression or death. In one embodiment, time to response (TTR) means the time from the first dose of a compound to the first documentation of a response. In one embodiment, TTR means the time from the first dose of a compound to the first documentation of a partial response (PR) ppp response. As a last resort, complete inhibition is referred to herein as a warning or chemoprevention. As used herein, the term prevention includes either complete prevention of the onset of clinically obvious cancer or prevention of the onset of a preclinically obvious stage of cancer. Also intended to be covered by this definition is preventing transformation into malignant cells or arresting or reversing the progression of benign cells to malignant cells. This includes preventive treatment for individuals at increased risk of developing cancer.

In the context of multiple myeloma, response can be assessed using the International Myeloma Working Group (IMWG) consensus criteria for response and minimal residual disease assessment (Rajkumar et al., Blood, 2011, 117(18): 4691-5; Kumar et al., Lancet Oncol, 2016,17(8):e328e346). The criteria can be assessed as follows (more information available in Lancet Oncol, 2016,17(8):e328-e346).

- 7 043592

Response Criteria MWG MRD Criteria (full response required as defined below) Sustainable MOB- negative MRD negativity by bone marrow (NGF or NGS, or both) and imaging, as defined below, was confirmed at minimum 1-year intervals. Subsequent assessments can be used to clarify the duration of negativity (eg, MRD negative after 5 years) MRD negative based on flow cytometry Absence of phenotypically aberrant clonal plasma cells by NGF on bone marrow aspirates using the EuroFlow standard operating procedure for detection of MRD in multiple myeloma (or a validated equivalent method) with a minimum sensitivity of 1 in 10 ⁵ nucleated cells or better MRD-negative on sequencing basis Absence of clonal plasma cells by NGS on a bone marrow aspirate, in which the presence of a clone is defined as the presence of fewer than two identical sequencing reads obtained after DNA sequencing of bone marrow aspirates using the LymphoSIGHT platform (or a validated equivalent method) with a minimum sensitivity of 1 in 10 ⁵ nuclear cells or higher MRD-negative on based on visualization "plus" MRD negativity, as determined by NGF or NGS, plus disappearance of each area of increased uptake detected at baseline or prior PET/CT, or reduction of the SUV mediastinal blood pool to less than that of surrounding normal tissue

- 8 043592

IMWG Standard Response Criteria Strict complete answer Complete response as defined below, plus normal FLC ratio and absence of clonal cells on bone marrow biopsy by immunohistochemistry (κ/λ ratio <4:1 or >1:2 for patients with k and λ, respectively, after counting >100 plasma cells cells) Full answer Negative immunofixation in serum and urine and disappearance of any soft tissue plasmacytomas and <5% plasma cells in bone marrow aspirates Very good partial answer Serum and urine M protein detected by immunofixation but not electrophoresis or >90% decrease in serum and urine M protein levels <100 mg within 24 hours Partial answer Reduction of M-protein in serum >50% and decrease in M-protein in urine >90% or to <200 mg within 24 hours; If serum and urine M protein are not measurable, a >50% reduction in the difference between involved and uninvolved FLC levels is required instead of the M protein criteria; If serum and urine M protein is unmeasurable and the facilitated serum-free assay is also unmeasurable, a >50% plasma cell reduction is required instead of M protein, provided the baseline percentage of bone marrow plasma cells was >30%. In addition to these criteria, size reduction (SPD) of soft tissue plasmacytomas >50% is also required if they are present at baseline Minimum answer A decrease in serum M-protein by >25% but <49% and a decrease in M-protein in 24-hour urine by 50-89%. In addition to the above criteria, size reduction (SPD) of soft tissue plasmacytomas >50% is also required if present at baseline

- 9 043592

Stable disease Not recommended for use as a response indicator; Disease persistence is best described by estimating the time to disease progression. Not meeting criteria for complete response, very good partial response, partial response, minimal response, or progressive disease Progressive disease Any one or more of the following criteria: An increase of 25% from the lowest value of the confirmed response in one or more of the following criteria: Serum M-protein (absolute increase should be >0.5 g/dL); Increase in serum M protein >1 g/dL if the lowest M component was >5 g/dL; M-protein in urine (absolute increase should be >200 mg/24 h); In patients without measurable levels of Mprotein in serum and urine, the difference between the levels of involved and non-involved FLC (absolute increase should be >10 mg/dL); In patients without measurable levels of M-protein in serum and urine and without measurable levels of involved FLC, the percentage of bone marrow plasma cells regardless of baseline (absolute increase should be >10%); Appearance of new lesion(s), >50% increase from nadir in SPD >1 lesion, or >50% increase in longest diameter of previous lesion >1 cm short axis; >50% increase in circulating plasma cell count (minimum 200 cells per µl) if this is the only indicator of disease

- 10 043592

Clinical relapse Clinical relapse requires the presence of one or more of the following criteria: Direct indicators of increasing disease and/or end organ dysfunction (CRAB features) associated with an underlying clonal disorder of plasma cell proliferation. It is not used to calculate time to progression or progression-free survival, but is listed as something that can be reported optionally or for use in clinical practice; Development of new soft tissue plasmacytomas or bone lesions (osteoporotic fractures are not considered progression); Definite increase in size of existing plasmacytomas or bone lesions. Defined enlargement is defined as an enlargement of 50% (and >1 cm) measured serially using the SPD of the lesion being measured; Hypercalcemia (> 11 mg/dL); A decrease in hemoglobin >2 g/dL not related to therapy or other conditions not related to myeloma; An increase in serum creatinine of 2 mg/dL or more since the start of therapy, which may be associated with myeloma; Hyperviscosity associated with serum paraprotein Relapse after complete response (only used if endpoint is survival without diseases) Any one or more of the following criteria: Reappearance of M protein in serum or urine by immunofixation or electrophoresis; Development of >5% plasma cells in bone marrow; Appearance of any other signs of progression (eg, new plasmacytoma, lytic bone lesion, or hypercalcemia, see above) Relapse after MRD negative (only used if the end point is survival without diseases) Any one or more of the following criteria: Loss MRD negative (evidence of clonal plasma cells on NGF or NGS, or positive imaging for relapse of myeloma); Reappearance of M protein in serum or urine during immunofixation or electrophoresis; Development of >5% clonal plasma cells in the bone marrow; The appearance of any other signs of progression (eg, new plasmacytoma, lytic bone lesion, or hypercalcemia)

O3=minimal residual disease. NGF=npOTO4Han next generation cytometry. NGS=next generation sequencing. PEC=free light chain. M protein = myeloma protein. SPD=cyMMa of the products of the maximum perpendicular diameters of the measured damage. Signs of SCAV=increased calcium levels, renal failure, anemia, lytic bone lesions. FCM=flow cytometry. 8iUsha = maximum standardized absorbance value. ¹⁸ F-FDG PET= ¹⁸ E-fluorine deoxyglucose PET.

In some embodiments, treatment of multiple myeloma may also be assessed using the International Uniform Response Criteria for Multiple Myeloma (IURC) (see Durie BGM, Harousseau J-L, Miguel JS, et al. International uniform response criteria for multiple myeloma. Leukemia, 2006; (10)10:1-7), using the definition of response and endpoint as shown below:

- 11 043592

Subcategory Reply Answer criteria ^a SPO PO as defined below and Normal FLC ratio and Absence of clonal cells in bone marrow ^by immunohistochemistry or immunofluorescence ⁰ BY Negative immunofixation in serum and urine and Disappearance of any soft tissue plasmacytomas and <5% of plasma cells in the bone marrow ^b OHCHO Serum and urine M protein detected by immunofixation but not electrophoresis or 90% or greater decrease in serum and urine M protein levels <100 mg within 24 hours CHO Serum M protein decrease >50% and urine M protein decrease >90% or <200 mg within 24 hours If serum and urine M-protein is unmeasurable^ >50%, a reduction in the difference between involved and uninvolved FLC levels is required instead of the M-protein criteria If serum and urine M-protein is unmeasurable and the facilitated serum-free assay is also unmeasurable, a >50% plasma cell reduction is required instead of M-protein, provided the baseline bone marrow plasma cell percentage was >30% In addition to the above criteria, a >50% reduction in size of soft tissue plasmacytomas if present at baseline is also required NW (not recommended for use as a response indicator; disease persistence is best described by estimating the time to disease progression) Not meeting the criteria for CR, OCCR, PR or progressive disease

Abbreviations: software, full answer; FLC, free light chain; PR, partial response; SD, disease stabilization; sPO, strict full answer; OHCHOO, very good partial answer.

^a All response categories require two consecutive assessments made at any time before the establishment of any new therapy; all categories also require evidence of the absence of progressive or new bone lesions if radiographic examinations have been performed. Radiological examinations are not required to satisfy these response requirements.

^b Confirmation with repeat bone marrow biopsy is not required.

^c The presence/absence of clonal cells is based on the κ/λ ratio. An abnormal κ/λ ratio by immunohistochemistry and/or immunofluorescence requires a minimum of 100 plasma cells for analysis. The abnormal ratio, reflecting the presence of an abnormal clone, is κ/λ >4:1 or <1:2.

^d Measurable disease is defined by at least one of the following: bone marrow plasma cells >30%; serum M protein >1 g/dL (>10 g/L) [10 g/L]; M-protein in urine > 200 mg/24 h; Serum FLC assay: involved FLC level >10 mg/dL (>100 mg/L); provided that the serum FLC ratio is abnormal.

ECOG status as used herein refers to the Eastern Cooperative Oncology Group (ECOG) performance status (Oken M, et al Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982;5(6):649 -655), illustrated below:

- 12 043592

Point Description 0 Fully active, able to do everything as before the disease without limitation 1 Limited in activity to perform physically demanding work, but can do light or sedentary work, such as light housework, office work. 2 He is receiving treatment as an outpatient and is capable of self-care, but is unable to perform any work. Spends more than 50% of waking time actively - in an upright position. 3 Capable of only limited self-care, spends more than 50% of waking time in a chair or bed. 4 Completely disabled. Completely incapable of self-care. Completely confined to bed or chair 5 Dead

As used herein, the term about, unless otherwise indicated, when used in conjunction with a numerical value or range of values, indicates that the value or range of values may vary to an extent considered reasonable by one skilled in the art. In one embodiment, the term about means that the numerical value or range of values may vary between 25%, 20%, 15%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3% , 2%, 1.5%, 1%, 0.5% or 0.25% of the specified value or range of values. In one embodiment, the term about refers to a value that is no more than 10% greater or less than the value modified by the term. For example, the term about 10 mg/m ² means a range of 9 to 11 mg/m ² .

The terms BCMA, target BCMA, human BCMA as used herein refers to human B cell maturation antigen, also known as BCMA, TR17_HUMAN, TNFRSF17 (UniProt Q02223), which is a member of the tumor necrosis receptor family that is preferentially expressed in differentiated cells plasma. The extracellular domain of BCMA consists, according to UniProt, of amino acids 1-54 (or 5-51). As used herein, the terms anti-BCMA antibody, anti-BCMA antibody refers to an antibody that specifically binds to the extracellular domain of BCMA.

The terms BCMA specific binding or BCMA binding refer to an antibody that is capable of binding to a target BCMA with sufficient affinity such that the antibody can be used as a therapeutic agent to target BCMA. In some embodiments, the extent of binding of the anti-BCMA antibody to an unrelated non-BCMA protein is about 10-fold, preferably >100-fold, less than the binding of the antibody to BCMA, as measured, for example, by surface plasmon resonance. (SPR) such as Biacore®, enzyme-linked immunosorbent assay (ELISA) or flow cytometry (FACS). In one embodiment, the antibody that binds to BCMA has a dissociation constant (Kd) of 10 ^-8 M or less, in one embodiment from 10 ^-8 M to 10 ^-13 M, in one embodiment from 10 ^-9 M up to 10 ^-13 M. In one embodiment, the anti-BCMA antibody binds to a BCMA epitope that is conserved among BCMA of different species, in one embodiment, between human and cynomolgus monkey, and in a further embodiment, also with mouse and rat BCMA. The terms bispecific antibody that specifically binds to CD3 and BCMA, bispecific antibody to CD3 and BCMA refers to the respective definition of binding to both targets. An antibody that specifically binds to BCMA (or BCMA and CD3) does not bind to other human antigens. Therefore, in an ELISA, the OD values for such unbound targets will be equal to or below the detection limit of the particular assay, in one embodiment >0.3 ng/ml, or equal to or below the OD values of control samples bound to the BCMA plate or to untransfected FIEK293 cells.

As used herein, the term APRIL refers to recombinant truncated mouse APRIL (amino acids 6-10241; NP_076006). APRIL can be produced as described in Ryan, 2007 (Mol Cancer Ther; 6 (11): 3009-18).

As used herein, the term BAFF refers to recombinant truncated human BAFF (UniProt Q9Y275 (TN13B_HUMAN)), which can be prepared as described in Gordon, 2003 (Biochemistry; 42 (20): 5977-5983). In one embodiment, the invention uses a His-tagged BAFF.

In one embodiment, a His-tagged BAFF is produced by cloning a DNA fragment encoding BAFF residues 82-285 into an expression vector, fusion with an N-terminal His tag followed by a thrombin cleavage site, expressing the vector, and cleaving the reduced protein with thrombin .

- 13 043592

The term anti-CD3 antibody, anti-CD3 antibody refers to an antibody that specifically binds to CD3. In one embodiment, the antibody specifically binds to CD3ε. As used herein, the term CD3ε or CD3 refers to human CD3ε described in UniProt P07766 (CD3ε_HUMAN).

As used herein, the term antibody refers to a monoclonal antibody. An antibody consists of two pairs of light chain (LC) and heavy chain (HC) (such light chain (LQ/heavy chain) pairs are abbreviated herein as LC/HC). The light and heavy chains of such antibodies are polypeptides consisting of several domains.Each heavy chain contains a heavy chain variable region (abbreviated herein as HCVR or VH) and a heavy chain constant region.The heavy chain constant region contains the heavy chain constant domains CH1, CH2 and CH3 (antibody classes IgA, IgD and IgG) and, optionally, a heavy chain constant domain CH4 (antibody classes IgE and IgM). Each light chain contains a light chain variable domain VL and a light chain constant domain CL. The VH and VL variable domains can be further divided into regions of hypervariability called complementarity determining regions (CDR), interspersed with more conserved regions called framework regions (FR).Each VH and VL consists of three CDRs and four FRs, arranged from amino terminus to carboxy terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3 , FR4. The heavy chain and light chain constant domains are not directly involved in antibody binding to the target, but exhibit distinct effector functions. As used herein, the term antibody also includes a portion of an antibody that is required for at least specific binding to the CD3 antigen, respectively. BCMA. Therefore, such an antibody (or antibody portion) in one embodiment may be a Fab fragment if said antibody portion is included in a bispecific antibody of the invention. The antibody of the invention may also be a Fab', F(ab') ₂ , scFv, di-scFv or bispecific T cell activator (BiTE®).

The term antibody includes, for example, murine antibodies, human antibodies, chimeric antibodies, humanized antibodies and genetically engineered antibodies (variant or mutant antibodies) so long as their characteristic properties are retained. In one embodiment, the antibodies are human or humanized antibodies, especially in the form of recombinant human or humanized antibodies. Additional embodiments are heterospecific antibodies (bispecific, trispecific, etc.) and other conjugates, such as cytotoxic small molecules.

Bispecific antibody formats are well known in the art and, for example, are also described in Kontermann RE, mAbs 4:2 1-16 (2012); Holliger P, Hudson PJ, Nature Biotech.23 (2005) 11261136 and Chan AC, Carter PJ Nature Reviews Immunology 10, 301-316 (2010), and Cuesta AM et al., Trends Biotech 28 (2011) 355-362. As used herein, the term bispecific antibody refers in one embodiment to an antibody in which one of two heavy chain/light chain (HC/LC) pairs specifically binds to CD3 and the other specifically binds to BCMA. The term also refers to other bispecific antibody formats in accordance with the prior art. In one embodiment, the term bispecific antibody includes bispecific single chain antibodies such as BiTE® antibodies, DART antibodies, diabodies, tandem scFvs and antibody mimetics such as DARP-ins. In one embodiment, a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) is one of the antibodies described in International Application Publication No. WO 2018/083204, which is incorporated herein in its entirety by links.

As used herein, the term TCB refers to a bispecific antibody that specifically binds to BCMA and CD3. As used herein, the term 83A10-TCBcv refers to a bispecific antibody that specifically binds to BCMA and CD3, as defined by the combination of its heavy and light chains SEQ ID NO: 45, SEQ ID NO: 46, SEQ ID NO: 47 (2x) and SEQ ID NO: 48, as shown in FIG. 2A and described in EP 14179705. As used herein, the terms 21TCBcv, 22-TCBcv, 42-TCBcv refer to the corresponding Mab21 bispecific antibodies, as defined by the combination of its heavy and light chains with SEQ ID NO: 48, SEQ ID NO: 49, SEQ ID NO: 50 and SEQ ID NO: 51 (2x), Mab 22, as defined by the combination of its heavy and light chains with SEQ ID NO: 48, SEQ ID NO: 52, SEQ ID NO: 53 and SEQ ID NO: 54 (2x), and Mab42, as defined by the combination of its heavy and light chains with SEQ ID NO: 48, SEQ ID NO: 55, SEQ ID NO: 56 and SEQ ID NO: 57-(2x).

B. Brief description of the figures

Fig. 1A and 1B: Bispecific divalent antibodies containing only Fab fragments (specific for CD3 and BCMA) and Fc part, as indicated: (Fig. 1A) Fab BCMA(RK/EE)-Fc-Fab CD3; (Fig. 1B) Fab BCMA-Fc-Fab CD3(RK/EE). Amino acid substitutions for RK/EE introduced in CL-CH1 to reduce LC mismatches/by-products in production. The CD3 Fab contains a VL-VH crossover to reduce mismatched LCs and byproducts.

Fig. 2A-2D: Preferred bispecific trivalent antibodies containing only

- 14 043592

Fab fragments (specific for CD3 and BCMA) and Fc portion as indicated: (Fig. 2A) Fab BCMA(RK/EE)Fc-Fab CD3-Fab BCMA(RK/EE); (Fig. 2B) Fab BCMA-Fc-Fab CD3(RK/EE)-Fab BCMA; (Fig. 2C) Fab BCMA(RK/EE)-Fc-Fab BCMA(RK/EE)-Fab CD3; (Fig. 2D) Fab BCMA-Fc-Fab BCMA-Fab CD3(RK/EE). Amino acid substitutions for RK/EE introduced in CL-CH1 to reduce LC mismatches/by-products in production. Preferably, the CD3 Fab contains a VL-VH crossover to reduce the number of LC mismatches and by-products. Preferably, Fab CD3 and Fab BCMA are linked to each other by flexible linkers.

Fig. 3A-3D: Bispecific bivalent antibodies containing only Fab fragments (specific for CD3 and BCMA) and the Fc part, as indicated: (Fig. 3A) Fc-Fab CD3-Fab BCMA(RK/EE); (Fig. 3B) Fc-Fab CD3(RK/EE)-Fab BCMA; (Fig. 3C) Fc-Fab BCMA(RK/EE)-Fab CD3; (Fig. 3D) Fc-Fab BCMA-Fab CD3(RK/EE). Preferably, CD3 Fabs contain a VL-VH crossover to reduce the number of LC mismatches and by-products. Fab CD3 and Fab BCMA are connected to each other by flexible linkers.

In fig. 4A-4C show that pretreatment of effector T cells or multiple myeloma (MM) cells or target PCL cells with Compound 2 increases the efficacy, and in some cell lines also increases the maximum killing of target cells achieved with bispecific antibodies that specifically bind with human B cell maturation antigen (BCMA) and with human CD3ε (CD3) proposed herein. Effector T cells (CD3+) were pretreated with DMSO (control) or Compound 2 (1 nM) for 16 h, then washed and used for co-cultures. Target cell lines H929 (Fig. 4A), L363 (Fig. 4B), and OPM-2 (Fig. 4C) were pretreated with DMSO (control) or Compound 2 (1 nM) for 72 h, then washed and used for co cultivation at a ratio of effector T cells (E) to target cells (T) of 1:3, 1:1 and 1:5, respectively. DMSO-DMSO lines: target and effector cells pretreated with DMSO (controls). Lines Compound 2-DMSO: target cells pre-treated with Compound 2, effector cells pre-treated with DMSO (control). DMSO-Compound 2 lines: target cells pretreated with DMSO (control), effector cells pretreated with Compound 2. Compound 2-Compound 2 lines: both target and effector cells pretreated with Compound 2. The y-axis represents the percentage living tumor cells normalized to the number of living cells in the absence of bispecific antibodies; The x-axis represents ^[concentration] of bispecific antibody in pM.

In fig. 5 shows that Compound 2 enhances the potency and maximum target cell killing achieved by the bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3s (CD3) provided herein. Effector T cells (CD3 + ) from three different donors were co-cultured with the target cell line MM H929 at a fixed ratio of effector T cells (E) to target cells (T) 1:3 in the presence of DMSO (control) or Compound 2 (1 nM) for 72 hours. The y-axis represents the percentage of live tumor cells normalized to the number of live cells in the absence of bispecific antibodies; The x-axis represents ^[concentration] of bispecific antibody in pM.

In fig. 6 shows that pretreatment of lenalidomide-resistant multiple myeloma cells with Compound 2, but not with pomalidomide, increases the potency and maximum target cell killing achieved by a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3s (CD3). ) proposed in this document. The target cell line H929-1051 was pretreated with DMSO (control), pomalidomide (100 nM) or Compound 2 (1 nM) for 72 h, then washed and used for co-culture at the ratio of effector T cells (E) to cells - targets (T) 1:3. The y-axis represents the percentage of live tumor cells normalized to the number of live cells in the absence of bispecific antibodies; The x-axis represents ^[concentration] of bispecific antibody in pM.

C. Connections

For use in the methods proposed herein, the compound 4-(4-(4(((2-(2,6-dioxopiperidin-3-yl)-1-oxoisoindolin-4-yl)oxy)methyl)benzyl) is provided. piperazin-1-yl)-3-fluorobenzonitrile, referred to as Compound 1:

O

or an enantiomer, mixture of enantiomers, tautomer, isotopologue or pharmaceutically acceptable salt thereof.

- 15 043592

Also provided for use in the methods provided herein is the compound (S)4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1-oxoisoindolin-4-yl)oxy )methyl)benzyl)piperazin-1-yl)-3fluorobenzonitrile, referred to as Compound 2:

or a tautomer, isotopologue or pharmaceutically acceptable salt thereof.

Also provided for use in the methods provided herein is the compound (R)-4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1-oxoisoindolin-4-yl) oxy)methyl)benzyl)piperazin-1-yl)3-fluorobenzonitrile, referred to as Compound 3:

O

or a tautomer, isotopologue or pharmaceutically acceptable salt thereof.

D. Preparation of compounds 1, 2 and 3

Compounds for use in the methods proposed herein can be prepared by methods known to one skilled in the art, and by methods similar to those described in the Examples section of this document, and customary modifications thereof. A typical reaction scheme for the preparation of these compounds is illustrated below in Scheme 1 for Compound 1, Compound 2 and Compound 3 and Scheme 2 for Compound 2.

As shown in Scheme 1, protection of 3-hydroxy-2-methylbenzoic acid (using, for example, methyl ester formation and tert-butyl(dimethyl)silyl ether) was followed by bromination, for example using N-bromosuccinimide and azobiisobutyronitrile. Reaction with methyl 4,5-diamino-5-oxopentanoate in the presence of a base (such as DIPEA) resulted in the isoindoline derivative, followed by deprotection of TBS using a base such as potassium carbonate. Reaction of the substituted isoindoline with 1,4bis(bromomethyl)benzene in the presence of a base (such as potassium carbonate) resulted in the formation of glutarimide in the presence of potassium tert-butoxide. Finally, reaction with 3-fluoro-4-(piperazin-1yl)benzonitrile gave the title compound 1. Compound 2 and Compound 3 were then obtained by chiral resolution.

Scheme 1

DIEA, AcN

Alternatively, as illustrated in Scheme 2, the reaction of the intermediate methyl 2-(bromomethyl)-3-[tert-butyl(dimethyl)silyl]oxybenzoate with chiral tert-butyl (4S)-4,5diamino-5-oxo-pentanoate in the presence of a base (such as DIPEA), produces a substituted isoindoline, followed by deprotection of TBS using tetrabutylammonium fluoride. Reaction of the substituted isoindoline with 4-(4-(4-(chloromethyl)benzyl)piperazin1-yl)-3-fluorobenzonitrile in the presence of a base (such as potassium carbonate) resulted in the formation of glutarimide to give the title compound 2.

Scheme 2

One skilled in the art will appreciate how to modify the procedures set forth in the illustrative diagrams and examples to obtain the desired products.

E. Bispecific antibody that specifically binds to BCMA and CD3

Proposed for use in the methods herein is a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3s (CD3).

In one embodiment, the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3e (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region with SEQ ID NO: 21, a CDR2H region with SEQ ID NO: 22, and a CDR3H region with SEQ ID NO: 17, and a VL region containing a CDR3L region with SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3s (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region with SEQ ID NO: 21, a CDR2H region with SEQ ID NO: 22 and a CDR3H region with SEQ ID NO: 17, and a VL region containing a CDR3L region with SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

a) the CDR1L region with SEQ ID NO: 25 and the CDR2L region with SEQ ID NO: 26, or

b) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, the first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: 20, region CDR1L with SEQ ID NO: 23 and region

CDR2L with SEQ ID NO: 24.

In one embodiment, the first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: 20, the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26.

In one embodiment, the first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: 20, the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3s (CD3), wherein the first binding portion comprises a VH region of SEQ ID NO: 10 and region VL with SEQ ID NO: 12, region VH with SEQ ID NO: 10 and region VL with SEQ ID NO: 13, or region VH with SEQ ID NO: 10 and region VL with SEQ ID NO: 14.

In one embodiment, the first linking portion comprises the VH region of SEQ ID

- 17 043592

NO: 10 and region VL with SEQ ID NO: 12.

In one embodiment, the first linking portion comprises the VH region of SEQ ID

NO: 10 and region VL with SEQ ID NO: 13.

In one embodiment, the first linking portion comprises the VH region of SEQ ID

NO: 10 and region VL with SEQ ID NO: 14.

In one embodiment, the first binding moiety is characterized by comprising a VL region selected from the group consisting of the VL regions of SEQ ID NOs: 12, 13 and 14, wherein amino acid 49 is selected from the group of amino acids tyrosine (Y), glutamic acid (E ), serine (S) and histidine (H). In one embodiment, amino acid 49 is E in SEQ ID NO: 12, S in SEQ ID NO: 13, or H in SEQ ID NO: 14.

In one embodiment, the first binding moiety is characterized by comprising a VL region selected from the group consisting of the VL regions of SEQ ID NOs: 12, 13, and 14, wherein amino acid 74 is threonine (T) or alanine (A). In one embodiment, amino acid 74 is A in SEQ ID NO: 14.

In one embodiment, the first linking portion is characterized in that, as the VH, the BCMA contains the VH region of SEQ ID NO: 10.

In one embodiment, the first binding moiety is characterized by comprising a VL region selected from the group consisting of the VL regions of SEQ ID NOs: 12, 13 and 14, wherein amino acid 49 is selected from the group of amino acids tyrosine (Y), glutamic acid (E ), serine (S) and histidine (H). In one embodiment, amino acid 49 is E (SEQ ID NO: 12), S (SEQ ID NO: 13) or H (SEQ ID NO: 14). In one embodiment of the invention, the first binding moiety is characterized by comprising a VL region selected from the group consisting of the VL regions of SEQ ID NOs: 12, 13 and 14, wherein amino acid 74 is threonine (T) or alanine (A). In one embodiment, amino acid 74 is A in SEQ ID NO: 14.

In one embodiment, the first binding portion is characterized by comprising a CDR3H region of SEQ ID NO: 17 and a CDR3L region of SEQ ID NO: 2o and a combination of CDR1H, CDR2H, CDR1L and CDR2L regions selected from the group a) CDR1H region of SEQ ID NO: 21 and CDR2H regions with SEQ ID NO: 22, CDR1L regions with SEQ ID NO: 23 and CDR2L regions with SEQ ID NO: 24, b) CDR1H regions with SEQ ID NO: 21 and CDR2H regions with SEQ ID NO: 22 , CDR1L region of SEQ ID NO: 25 and CDR2L region of SEQ ID NO: 26, c) CDR1H region of SEQ ID NO:21 and CDR2H region of SEQ ID NO: 22, CDR1L region of SEQ ID NO:27 and CDR2L region with SEQ ID NO: 28, d) CDR1H region with SEQ ID NO: 29 and CDR2H region with SEQ ID NO: 30, CDR1L region with SEQ ID NO: 31 and CDR2L region with SEQ ID NO: 32, e) CDR1H region with SEQ ID NO: 34 and CDR2H regions with SEQ ID NO: 35, CDR1L regions with SEQ ID NO: 31 and CDR2L regions with SEQ ID NO: 32, and f) CDR1H regions with SEQ ID NO: 36 and CDR2H regions with SEQ ID NO: 37, CDR1L regions of SEQ ID NO: 31, and CDR2L regions of SEQ ID NO: 32.

In one embodiment, the first linking portion is characterized by comprising as a VH region a VH region selected from the group consisting of SEQ ID NOs: 38, 39, and 40. In one embodiment of the invention, the first linking portion is characterized by containing as a VH region, a VH region of SEQ ID NO: 38 and, as a VL region, a VL region of SEQ ID NO: 12. In one embodiment of the invention, the first linking portion is characterized by comprising, as a VH region, a VH region of SEQ ID NO: 39 and as the VL region, the VL region having SEQ ID NO: 12. In one embodiment of the invention, the first linking part is characterized by comprising, as the VH region, the VH region having SEQ ID NO: 40 and, as the VL region, the VL region having SEQ ID NO: 12.

In one embodiment, the first binding moiety is characterized by comprising a CDR1H region of SEQ ID NO: 15, a CDR2H region of SEQ ID NO: 16, a CDR3H region of SEQ ID NO: 17, a CDR1L region of SEQ ID NO: 18, a CDR2L region with SEQ ID NO: 19 and the CDR3L region with SEQ ID NO: 20.

The first binding part of the invention contains as CDR3H and CDR3L regions the same CDR regions as antibody 83A10 (for antibody 83A10, see Table 1A and B below).

In one embodiment, the first linking portion is characterized by comprising, as the VH region, the VH region of SEQ ID NO: 9 and, as the VL region, the VL region of SEQ ID NO: 11.

In one embodiment, the bispecific antibody comprises no more than one Fab fragment of an anti-CD3 antibody portion, no more than two Fab fragments of an anti-BCMA antibody portion, and no more than one Fc portion, in one embodiment a human Fc portion. In one embodiment, at most one Fab fragment of the anti-CD3 antibody portion and at most one Fab fragment of the anti-BCMA antibody portion are linked to the Fc portion, and the binding is accomplished by C-terminal binding of the Fab fragment(s) to the hinge region. In one embodiment, the second Fab fragment of the anti-BCMA antibody portion is linked at its C-terminus to either the N-terminus of the Fab fragment of the anti-CD3 antibody portion or to the hinge region of the Fc portion and, therefore, between the Fc portion and the anti-CD3 antibody portion. Preferred bispecific antibodies are shown in FIG. 1A, 1B, 2A-2D and 3A-3D

Particularly preferred are bispecific antibodies containing only Fab fragments and an Fc portion with or without amino acid substitution: Fab BCMA-Fc-Fab. CD3 (bispecific

- 18 043592 format fig. 1A or FIG. 1B), Fab BCMA-Fc-Fab CD3-Fab BCMA (bispecific format of Fig. 2A or Fig. 2B), Fab BCMA-Fc-Fab BCMA-Fab CD3 (bispecific format of Fig. 2C or Fig. 2d), Fc-Fab

CD3-Fab BCMA (bispecific format of Fig. 3A or Fig. 3B), Fc-Fab BCMA-Fab CD3 (bispecific format of Fig. 3C or Fig. 3D).

As shown in FIG. 1A, 1B, 2A to 2D and 3A to 3D, Fab BCMA-Fc, Fab BCMA-Fc-Fab CD3 and Fab BCMA-Fc-Fab CD3 mean that the Fab fragment(s) are linked through its ) C-terminus with N-terminus of the Fc fragment. Fab CD3-Fab BCMA means that the Fab fragment of CD3 is linked at its N-terminus to the C-terminus of the Fab fragment of BCMA. Fab BCMA-Fab CD3 means that the BCMA Fab fragment is linked at its N-terminus to the C-terminus of the CD3 Fab fragment.

In one embodiment, the bispecific antibody comprises a second Fab fragment of said anti-BCMA antibody linked at its C-terminus to the N-terminus of the anti-CD3 antibody portion of said bispecific antibody. In one embodiment, the VL domain of said first region of the anti-CD3 antibody is linked to the CH1 or CL domain of said second anti-BCMA antibody.

In one embodiment, the bispecific antibody comprises a second Fab fragment of said anti-BCMA antibody linked at its C-terminus to an Fc portion (similar to a first Fab fragment of said anti-BCMA antibody) and linked at its N-terminus to a C-terminus portion of the anti-CD3 antibody. In one embodiment, the CH1 domain of said anti-CD3 antibody portion is linked to the VH domain of said second anti-BCMA antibody portion.

In one embodiment, the bispecific antibody comprises an Fc moiety linked at its N-terminus to the C-terminus of a Fab fragment of said anti-CD3 antibody. In one embodiment, the bispecific antibody comprises an Fc portion linked at its first N-terminus to the C-terminus of said Fab fragment of an anti-CD3 antibody, and a second Fab fragment of said anti-BCMA antibody linked at its C-terminus to a second N-terminus of the Fc -parts. In one embodiment, the CL domain of an anti-CD3 antibody Fab fragment is linked to the hinge region of the Fc portion. In one embodiment, the CH1 domain of an anti-BCMA antibody Fab fragment is linked to the hinge region of the Fc portion.

The Fab fragments are linked together using a suitable linker in accordance with the prior art. In one embodiment, linker (Gly4-Ser1) 3 is used (Desplancq DK et al., Protein Eng. 1994 Aug;7(8): 1027-33 and Mack M. et al., PNAS July 18, 1995 vol. 92 no. 15 7021-7025). Since the linker is a peptide linker, such covalent linking is typically accomplished by biochemical recombination methods using the nucleic acid encoding the VL and/or VH domains of the respective Fab fragments, the linker and, if necessary, the Fc portion chain.

In one embodiment, the anti-CD3ε antibody comprises a variable domain VH comprising a heavy chain CDR of SEQ ID NOs: 1, 2 and 3, as heavy chain CDR1H, CDR2H and CDR3H, respectively, and a variable domain VL comprising a light chain CDR of SEQ ID NO: 4, 5 and 6 indicate light chain CDR1L, CDR2L and CDR3L, respectively. In one embodiment, the antibody contains the variable domains of SEQ ID NO: 7 (VH) and SEQ ID NO: 8 (VL).

In one embodiment, the bispecific antibody is characterized in that the variable domains of the anti-CD3 antibody portion are SEQ ID NO:7 and 8.

In one embodiment of the invention, the bispecific antibody is characterized in that the anti-CD3 antibody portion (the second binding portion of the bispecific antibody) is linked at its N-terminus to the C-terminus of the anti-BCMA antibody portion (the first binding portion of the bispecific antibody) and the variable domains of the VL and VH portions Antibodies to CD3 or constant domains CL and CH1 are replaced by each other.

In one embodiment, the VH domain of said portion of the anti-CD3 antibody is linked to the CH1 or CL domain of said portion of the anti-BCMA antibody. In one embodiment, the VL domain of said portion of the anti-CD3 antibody is linked to the CH1 or CL domain of said portion of the anti-BCMA antibody.

In one embodiment, such part of the antibody is a Fab fragment of the corresponding antibody.

A bispecific antibody to BCMA and CD3 is in one embodiment characterized in that it contains a light chain and a heavy chain of an antibody that specifically binds to one of said CD3 and BCMA targets; and a light chain and a heavy chain of an antibody that specifically binds to another of these targets, wherein the variable domains VL and VH or the constant domains CL and CH1 are replaced with each other.

In one embodiment, the VH domain of said portion of the anti-CD3 antibody is linked to the CH1 or CL domain of said portion of the anti-BCMA antibody. In one embodiment, the VL domain of said portion of the anti-CD3 antibody is linked to the CH1 or CL domain of said portion of the anti-BCMA antibody.

In a further embodiment, a bispecific antibody in which the VL and VH variable domains of the light chain and the corresponding heavy chain of the anti-CD3 antibody portion or the anti-BCMA antibody portion are replaced with each other is characterized by comprising the CL constant domain of the anti-CD3 antibody portion or the antibody portion to BCMA, where the amino acid at position 124 is independently replaced by lysine (K), arginine (R) or histidine (H) (Kabat numbering), and in the corresponding CH1 constant domain, amino acid at position 147 and amino acid at position 213 independently substituted with glutamic acid (E) or aspartic acid (D). In one embodiment, the antibody is monovalent in binding to CD3. In one embodiment, in addition to replacing the amino acid at position 124 in the CL constant domain, the amino acid at position 123 is independently replaced with lysine (K), arginine (R), or histidine (H) (hereinafter referred to as a charged variant exchange). In one embodiment, the antibody is monovalent for CD3 binding, and amino acid 124 is K, amino acid 147 is E, amino acid 213 is E, and amino acid 123 is R. In one embodiment, the bispecific antibody contains, among other things, the same BCMA binding moiety (in one embodiment, a Fab fragment). This also means that if the first BCMA binding moiety contains a charged variant exchange, then the second BCMA binding moiety contains the same charged variant interchange. (All amino acid numbering is done according to Kabat).

In one embodiment, the bispecific antibody is characterized in that it contains:

a) a first light chain and a first heavy chain of a first antibody that specifically binds to vCmA; And

b) a second light chain and a second heavy chain of the second antibody that specifically bind to CD3, wherein the VL and VH variable domains in the second light chain and the second heavy chain of the second antibody are replaced with each other; And

c) wherein in the CL constant domain of the first light chain according to a) the amino acid at position 124 is independently replaced by lysine (K), arginine (R) or histidine (H) (Kabat numbering), and wherein in the constant the CH1 domain of the first heavy chain under a) the amino acid at position 147 and the amino acid at position 213 are independently substituted with glutamic acid (E) or aspartic acid (D) (Kabat numbering) (see, for example, Fig. 1A, 2A, 2C, 3A, 3C).

In one embodiment, said bispecific antibody described in the last preceding paragraph is further characterized in that said bispecific antibody contains, among other things, a Fab fragment of said first antibody (hereinafter also referred to as BCMAFab), and in the CL constant domain said BCMA-Fab the amino acid at position 124 is independently substituted with lysine (K), arginine (R) or histidine (H) (Kabat numbering), and in the CH1 constant domain of said BCMA-Fab, the amino acid at position 147 and the amino acid at position 213 are independently substituted with glutamic acid (E) or aspartic acid (D) (Kabat numbering) (see, for example, Fig. 2A, 2C).

In one embodiment of the invention, the bispecific antibody consists of one CD3Fab, one BCMA-Fab, and an Fc portion, wherein the CD3-Fab and BCMA-Fab are linked by their C-termini to the hinge region of said Fc portion, and a second BCMA-Fab that is linked by its C-terminus. end with the N-terminus of CD3-Fab. CD3-Fab contains a crossover, and either CD3-Fab or both BCMA-Fab contain an amino acid substitution (Fig. 2A and 2B). Particularly preferred is a bispecific antibody comprising BCMAFab-Fc-CD3-Fab-BCMA-Fab, where both BCMA-Fab contains an amino acid substitution and the CD3-Fab contains a VL/VH crossover. (Fig. 2A). Particularly preferred is a bispecific antibody consisting of BCMA-Fab-Fc-CD3-Fab-BCMA-Fab, where both BCMA-Fab contains amino acid substitution Q124K, E123R, K147E and K213E, and CD3-Fab contains a VL/VH crossover. It is particularly preferred that both BCMA-Fabs contain CDR antibodies 21, 22 or 42, or VH/VL, VH/VL antibodies 21, 22 or 42 (for antibodies 21, 22 and 42, see Table 1A. and B below).

The first and second Fab fragments of the antibody that specifically bind to BCMA are, in one embodiment, derivatives of the same antibody and, in one embodiment, are identical in CDR sequences, VH and VL variable domain sequences, and/or CH1 constant domain sequences and CL. In one embodiment, the amino acid sequences of the first and second Fab fragments of an antibody that specifically binds to BCMA are identical. In one embodiment, the anti-BCMA antibody is an antibody comprising the CDR sequences of antibody 21, 22, or 42, an antibody containing the VH and VL sequences of antibody 21, 22, or 42, or an antibody comprising the VH, VL, CH1, and CL sequences of antibody 21 , 22 or 42.

In one embodiment, the bispecific antibody is characterized in that it contains:

a) a first light chain and a first heavy chain of a first antibody that specifically binds to BCMA; And

b) a second light chain and a second heavy chain of the second antibody that specifically bind to CD3, wherein the VL and VH variable domains in the second light chain and the second heavy chain of the second antibody are replaced with each other; and wherein

c) in this case, in the CL constant domain of the second light chain according to b) the amino acid at position 124 is independently substituted by lysine (K), arginine (R) or histidine (H) (Kabat numbering), and in this case the CH1 domain of the second heavy chain is in the constant under b) the amino acid at position 147 and the amino acid at position 213 are independently substituted with glutamic acid (E) or aspartic acid (D) (Kabat numbering).

- 20 043592

In one embodiment, in addition to replacing the amino acid at position 124 in the CL constant domain of the first or second light chain, the amino acid at position 123 is independently replaced with lysine (K), arginine (R), or histidine (H).

In one embodiment, in the CL constant domain, the amino acid at position 124 is replaced with lysine (K), and in the CH1 constant domain, the amino acid at position 147 and the amino acid at position 213 are replaced with glutamic acid (E). In one embodiment, among other things, in the CL constant domain, the amino acid at position 123 is replaced with arginine (R).

In one embodiment, the bispecific antibody consists of two BCMA-Fabs and an Fc portion, wherein one BCMA-Fab and CD3 Fab are linked through their C-terminal ends to the hinge region of said Fc portion, and a second BCMA-Fab is linked from its C-terminus to the N -end of CD3-Fab. CD3-Fab contains a crossover, and either CD3-Fab or both BCMA-Fab contain an amino acid substitution (Fig. 2A and 2B).

In one embodiment, the bispecific antibody is characterized in that each CH3 domain of one heavy chain and the CH3 domain of another heavy chain meet at an interaction boundary that includes the original interaction boundary between the CH3 domains of the antibody; wherein said interaction boundary is altered to facilitate the formation of a bispecific antibody, wherein the change is characterized in that the CH3 domain of one heavy chain is altered such that within the original interaction boundary of the one heavy chain CH3 domain, which meets the original interaction boundary of the CH3 domain of the other heavy chain in the bispecific antibody, an amino acid residue is replaced by an amino acid residue having a larger side chain volume, thereby creating a bulge at the interaction boundary of the CH3 domain of one heavy chain, which can be located in a cavity at the interaction boundary of the CH3 domain of another heavy chain and the CH3 domain of the other heavy chain is changed, so that within the original interaction boundary of the second CH3 domain, which meets the original interaction boundary of the first CH3 domain within the bispecific antibody, an amino acid residue is replaced by an amino acid residue having a smaller side chain volume, thereby creating a cavity at the interaction boundary of the second CH3 domain within which the protrusion at the interaction boundary of the first CH3 domain.

In one embodiment, the bispecific antibody is characterized in that said amino acid residue having a larger side chain volume is selected from the group consisting of arginine (R), phenylalanine (F), tyrosine (Y), tryptophan (W).

In one embodiment, the bispecific antibody is characterized in that said amino acid residue having a smaller side chain volume is selected from the group consisting of alanine (A), serine (S), threonine (T), valine (V).

In one embodiment, such a bispecific antibody is characterized in that both CH3 domains are further modified by introducing cysteine (C) as an amino acid at the corresponding positions of each CH3 domain.

In one embodiment, such a bispecific antibody is characterized in that one of the CH3 heavy chain constant domains of both heavy chains is replaced by a CH1 heavy chain constant domain; and the other heavy chain constant domain CH3 is replaced by the light chain constant domain CL.

In one embodiment, the bispecific antibody contains a modified Fc moiety that causes the death of 20% or more of the cells of the preparation of BCMA expressing cells after 24 hours at a concentration of said antibody of 100 nM using ADCC relative to a control under identical conditions using the same antibody with the parent Fc moiety as the control. Such an antibody in one embodiment is a pure antibody.

In one embodiment, the bispecific antibody is an antibody with an amount of fucose of 60% or less of the total amount of oligosaccharides (sugars) in Asn297 (see, for example, US 20120315268)

In one embodiment, the Fc portion contains amino acid substitutions that are introduced into the human Fc portion and are disclosed in SEQ ID NOs: 55 and 56.

In one embodiment, the anti-BCMA antibody is Mab21, Mab22, Mab42, Mab27, Mab33, and Mab39 (for Mab 21, 22, 42, 27, 33, 39, see Table 1A and B below), as described in herein their CDR sequences and/or VH/VL sequences together with the described CL and CH1 sequences. In one embodiment, the bispecific antibody may or may not contain an Fc portion, especially a 2+1 format, and the heavy and light chains of the bispecific antibody, particularly those described in Table 1. 1A.

Anti-BCMA antibody in a bispecific format, especially in the 2+1 format, depleted human malignant plasma cells in MM bone marrow aspirate to at least 80% after 48 hours of treatment at a concentration of 10 nM to 1 fM inclusive. Antibodies to BCMA were characterized by panning the variable heavy chain (VH) and variable light chain (VL) phage display library of antibody 83 A10 (VH library, VL library) with 1-50 nM

- 21 043592

Macaque BCMA in 1-3 rounds and selecting a light chain variable region and a heavy chain variable region that have properties such as bispecific T cell binding. Preferably, panning is performed in 3 rounds using 50 nM macaque BCMA for round 1, 25 nM macaque BCMA for round 2, and 10 nM macaque BCMA for round 3. Preferably, the libraries are randomized into either light chain CDR1 and CDR2 or heavy chain CDR1 and CDR2 . Preferably, light and heavy chains are identified, each of which binds as a Fab fragment containing, among other things, the corresponding VH or VL antibodies 83A10, to human BCMA with a Kd of 50 pM to 5 nM and to macaque BCMA with a Kd of 0.1 to 5 nM 20 nM. Preferably, the bispecific format is the format shown in FIG. 2A, containing the corresponding constant domains VL and VH substitutions of Fab CD3 with each other and within both Fab BCMA, amino acid substitutions K213E and K147E in the CH1 domain, and amino acid substitutions E123R and Q124K in the CL domain.

The bispecific antibody referred to herein can be produced by the steps of transforming a host cell with vectors containing nucleic acid molecules encoding the light chain and heavy chain of said antibody molecule, culturing the host cell under conditions that allow synthesis of said antibody molecule; and isolating said antibody molecule from said culture.

The bispecific antibody referred to herein can be produced by the steps of transforming a host cell with vectors containing nucleic acid molecules encoding a light chain and a heavy chain of the antibody specifically binding to the first target vectors containing nucleic acid molecules encoding a light chain and a heavy chain antibodies that specifically bind to a second target, where the variable domains VL and VH or the constant domains CL and CH1 are replaced by each other; culturing the host cell under conditions that ensure the synthesis of said antibody molecule; and isolating said antibody molecule from said culture.

In one embodiment, the bispecific antibody specifically binds to the extracellular domain of human BCMA and human CD3ε, characterized in that it contains a set of heavy and light chains selected from the group consisting of polypeptides:

i) SEQ ID NO: 48, SEQ ID NO: 49, SEQ ID NO: 50 and SEQ ID NO: 51 (2x) (TCB Antibody 21 Kit 1), ii) SEQ ID NO: 48, SEQ ID NO: 52, SEQ ID NO: 53 and SEQ ID NO: 54 (2x) (TSB Antibody 22 Set 2) and iii) SEQ ID NO: 48, SEQ ID NO: 55, SEQ ID NO: 56 and SEQ ID NO: 57 (2x) (set 3 TSV antibody 42). In one embodiment, the bispecific antibody specifically binds to the extracellular domain of human BCMA and to human CD3ε, characterized in that it contains a set of heavy and light chains selected from the group consisting of polypeptides SEQ ID NO: 48, SEQ ID NO: 49, SEQ ID NO: and SEQ ID NO: 51(2x) (TSB Antibody 21 Kit 1).

In one embodiment, the bispecific antibody specifically binds to the extracellular domain of human BCMA and to human CD3ε, characterized in that it contains a set of heavy and light chains selected from the group consisting of polypeptides SEQ ID NO: 48, SEQ ID NO: 52, SEQ ID NO: 53 and SEQ ID NO: 54 (2x) (set of 2 TCB antibodies 22).

In one embodiment, the bispecific antibody specifically binds to the extracellular domain of human BCMA and to human CD3ε, characterized in that it contains a set of heavy and light chains selected from the group consisting of polypeptides SEQ ID NO: 48, SEQ ID NO: 55, SEQ ID NO: 56 and SEQ ID NO: 57(2x) (TSB Antibody 42 Kit 3).

- 22 043592

Table 1A. Antibody sequences

SEQ ID NO: Title(s) Amino acid sequences 1 CDR1H CD3 TYAMN 2 CDR2H CD3 RIRSKYNNYATYYADSVKG 3 CDR3H CD3 HGNFGNSYVSWFAY 4 CDR1L CD3 GSSTGAVTTSNYAN 5 CDR2L CD3 GTNKRAP 6 CDR3L CD3 ALWYSNLWV 7 VHCD3 EVQLLESGGGLVQPGGSLRLSCAASGFTFSTYAMN WVRQAPGKGLEWVSRIRSKYNNYATYYADSVKGR FTISRDDSKNTLYLQMNSLRAEDTAVYYCVRHGNF GNS Y VSWF AYWGQGTL VT VS S 8 VLCD3 QAVVTQEPSLTVSPGGTVTLTCGSSTGAVTTSNYAN W VQEKPGQ AFRGLIGGTNKRAPGTP ARF SGSLLGG KAALTLSGAQPEDEAEYYCALWYSNLWVFGGGTK LTVL 9 VH83A10 EVQLLESGGGLVQPGGSLRLSC AASGFTF S S YAMS WVRQAPGKGLEWVSAISGSGGSTYYADSVKGRFTI SRDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFD YWGQGTLVTVSS 10 VHMab21 VH Mab22 VH Mab42 EVQLLESGGGLVQPGGSLRLSCAASGFTFSDNAMG WVRQAPGKGLEW VS AISGPGS STYYAD S VKGRFTIS RDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFDY WGQGTLVTVSS AND VL 83A10 EIVLTQSPGTLLSLSPGERATLSCRASQSVSSSYLAWY QQKPGQAPRLLIYGASSRATGIPDRFSGSGSGTDFTL TISRLEPEDFAVYYCQQYGYPPDFTFGQGTKVEIK 12 VLMab21 VL Mab27 VL Ma33 VL Mab39 EIVLTQSPGTLLSLSPGERATLSCRASQSVSEYYLAW YQQKPGQAPRLLIEHASTRATGIPDRFSGSGSGTDFT LTISRLEPEDFAVYYCQQYGYPPDFTFGQGTKVEIK 13 VL Mab22 EIVLTQSPGTLLSLSPGERATLSCRASQSVSSYYLAWY QQKPGQAPRLLISGAGSRATGIPDRFSGSGSGTDFTL TISRLEPEDFAVYYCQQYGYPPDFTFGQGTKVEIK 14 VL Mab42 EIVLTQSPGTLLSLSPGERATLSCRASQSVSDEYLSWY QQKPGQAPRLLIHSASTRATGIPDRFSGSGSGTDFTL AISRLEPEDFAVYYCQQYGYPPDFTFGQGTKVEIK 15 CDR1H83A10 SYAMS 16 CDR2H 83 AYU AISGSGGSTYYADSVKG

- 23 043592

17 CDR3H 83 AYU CDR3HMab21 CDR3H Mab22 CDR3H Mab42 CDR3H Mab27 CDR3HMab33 CDR3HMab39 VLGWFDY 18 CDR1L 83A10 RASQSVSSSYLAW 19 CDR2L 83АУ YGASSRAT 20 CDR3L 83АУ CDR3LMab21 CDR3L Mab22 CDR3L Mab42 QQYGYPPDFT 21 CDRlHMab21 CDR1H Mab22 CDR1H Mab42 DNAMG 22 CDR2H Mab21 CDR2H Mab22 CDR2H Mab42 AISGPGS STYYAD SVKG 23 CDRlLMab21 RASQSVSEYYLAW 24 CDR2L Mab21 EHASTRAT 25 CDR1L Mab22 RASQSVSSYYLAW

- 24 043592

26 CDR2L Mab22 SGAGSRAT 27 CDR1L Mab42 RASQSVSDEYLSW 28 CDR2L Mab42 HSASTRAT 29 CDR1H Mab27 SAPMG thirty CDR2H Mab27 AISYIGHTYYADSVKG 31 CDR1L Mab27 CDR1L MABLZZ CDR1L Mab39 RASQSVSEYYLA 32 CDR2L Mab27 CDR2L MABLZZ CDR2L Mab39 HASTRAT 33 CDR3L Mab27 CDR3L MABLZZ CDR3L Mab39 QQYGYPPDFT 34 CDR1H Ma33 TNAMG 35 CDR2H Ma33 AINRFGGSTYYADSVKG 36 CDRlHMab39 QNAMG 37 CDR2H Mab39 AISPTGFSTYYADSVKG 38 VH Mab27 EVQLLESGGGLVQPGGSLRLSC AASGFTF S S APMG WVRQAPGKGLEWVSAISYIGHTYYADSVKGRFTIS RDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFDY WGQGTLVTVSS

- 25 043592

39 VHMab33 EVQLLESGGGLVQPGGSLRLSCAASGFTFYTNAMG WVRQAPGKGLEWVSAINRFGGSTYYADSVKGRFTI SRDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFD YWGQGTLVTVSS 40 VHMab39 EVQLLESGGGLVQPGGSLRLSCAASGFTFTQNAMG WVRQAPGKGLEWVSAISPTGFSTYYADSVKGRFTIS RDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFDY WGQGTLVTVSS 41 CHI 83A10 k BCMA CHI Mab21 to BCMA CHI Mab22 to BCMA CHI Mab42 to BCMA ASTKGPSVFPLAPSSKSTSGGTAALGCLVEDYFPEPV TVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPS S SLGTQTYICNVNHKPSNTKVDEKVEPKSC 42 CL 83A10kBCMA CL Mab21 to BCMA CL Mab22 to BCMA CL Mab42 k BCMA RTVAAPSVFIFPPSDRKLKSGTASVVCLLNNFYPREA KVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTL TLSKADYEKHKVYACEVTHQGLSSPVTKSFNRGEC 43 CHI CD3 ASTKGPSVFPLAPSSKSTSGGTAALGCLVKDYFPEP VTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVP S S SLGTQT YICNVNHKP SNTK VDKKVEPK SC 44 CL CD3 ASVAAPSVFIFPPSDEQLKSGTASVVCLLNNFYPREA KVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTL TLSKADYEKHKVYACEVTHQGLSSPVTKSFNRGEC 45 NS projection 83A10 EVQLLESGGGLVQPGGSLRLSCAASGFTFSSYAMS WVRQAPGKGLEWVSAISGSGGSTYYADSVKGRFTI SRDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFD YWGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAA LGCLVEDYFPEPVTVSWNSGALTSGVHTFPAVLQSS GLYSLSSVVTVPSSSLGTQTYIC NVNHKPSNTKVDE KVEPKSCDGGGGSGGGGSQAVVTQEPSLTVSPGGT VTLTCGSSTGAVTTSNYANWVQEKPGQAFRGLIGG TNKRAPGTPARFSGSLLGGKAALTLSGAQPEDEAEY YCALWYSNLWVFGGGTKLTVLSSASTKGPSVFPLA PSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTS GVHTFPAVLQSS GLYSLSSVVTVPSSSLGTQTYICNV NHKPSNTKVDKKVEPKSCDKTHTCPPCPAPEAAGG PSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEV I<FNWYVDGVEVHNAI<TI<PREEQYNSTYRVVSVLT VLHQDWLNGKEYKCKVSNKALGAPIEKTISKAKGQ PREPQVYTLPPCRDE LTKNQVSLWCLVKGFYPSDIA VEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVD KSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

- 26 043592

46 NS depression 83A10 EVQLLESGGGLVQPGGSLRLSCAASGFTFSSYAMS WVRQAPGKGLEWVSAISGSGGSTYYADSVKGRFTI SRDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFD YWGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAA LGCLVEDYFPEPVTVSWNSGALTSGVHTFPAVLQSS GL YSLS S WT VP S S SL GTQT YICNVNHKPSNTKVDE KVEPKSCDKTHTCPPCPAPEAAGGPSVFLFPPKPKD TLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEV HNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKE YKCKVSNKALGAPIEKTISKAKGQPREPQVCTLPPS RDELTKNQVSLSCAVKGF YPSDIAVEWESNGQPEN NYKTTPPVLDSDGSFFLVSKLTVDKSRWQQGNVFS CSVMHEALHNHYTQKSLSLSPGK 47 LC 83A10 EIVLTQSPGTLSLSPGERATLSCRASQSVSSSYLAWY QQKPGQAPRLLIYGASSRATGIPDRFSGSGSGTDFTL TISRLEPEDFAVYYCQQYGYPPDFTFGQGTKVEIKR TVAAPSVFIFPPSDRKLKSGTASVVCLLNNFYPREA KVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTL TLSKADYEK HKVYACEVTHQGLSSPVTKSFNRGEC 48 LC CD3 EVQLLESGGGLVQPGGSLRLSCAASGFTFSTYAMN WVRQAPGKGLEWVSRIRSKYNNYATYYADSVKGR FTISRDDSKNTLYLQMNSLRAEDTAVYYCVRHGNF GNSYVSWFAYWGQGTLVTVSSASVAAPSVFIFPPSD EQLKSGTASVVCLLNNFYPREAKVQWKVDNALQS GNSQESVTEQDSK DSTYSLSSTLTLSKADYEKHKVY ACEVTHQGLSSPVTKSFNRGEC 49 NS ledge Mab21 EVQLLESGGGLVQPGGSLRLSCAASGFTFSDNAMG WVRQ APGKGLEW VS AISGPGS STYYAD S VKGRFTIS RDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFDY WGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAAL GCLVEDYFPEPVTVSWNSGALTSGVHTFPAVLQSSG LYSLSSVVTVPSSSLGTQ TYICNVNHKPSNTKVDEK VEPKSCDGGGGSGGGGSQAVVTQEPSLTVSPGGTV TLTCGSSTGAVTTSNYANWVQEKPGQAFRGLIGGT NKRAPGTPARF SGSLLGGKAALTLLSGAQPEDEAEY YCALWYSNLWVFGGGTKLTVLSSASTKGPSVFPLA PSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTS GVHTFP AVLQSSGLYSLSSVVTVPSSSLGTQTYICNV NHKPSNTKVDKKVEPKSCDKTHTCPPCPAPEAAGG PSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEV I<FNWYVDGVEVHNAI<TI<PREEQYNSTYRVVSVLT VLHQDWLNGKEYKCKVSNKALGAPIEKTISKAKGQ PREPQVY TLPPCRDELTKNQVSLWCLVKGFYPSDIA VEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVD KSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

- 27 043592

EVQLLESGGGLVQPGGSLRLSCAASGFTFSDNAMG W VRQAPGKGLEWVS AISGPGS STYYAD S VKGRFTIS RDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFDY WGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAAL GCLVEDYFPEPVTVSWNSGALTSGVHTFPAVLQSSG 50 NS depression Mab21 LYSLSSVVTVPSSSLGTQTYICNVNHKPSNTKVDEK VEPKSCDKTHTCPPCPAPEAAGGPSVFLFPPKPKDTL MISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVH NAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEY KCKVSNKALGAPIEKTISKAKGQPREPQVCTLPPSR DELTK NQVSLSCAVKGFYPSDIAVEWESNGQPENN YKTTPPVLDSDGSFFLVSKLTVDKSRWQQGNVFSCS VMHEALHNHYTQKSLSLSPGK EIVLTQSPGTLLSLSPGERATLSCRASQSVSEYYLAW YQQKPGQAPRLLIEHASTRATGIPDRFSGSSGTDFT 51 LC Mab21 LTISRLEPEDFAVYYCQQYGYPPDFTFGQGTKVEIK RTVAAPSVFIFPPSDRKLKSGTASVVCLLNNFYPREA KVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTL TLSKADYEKHKVYACEVTHQGLSSPVTKSFNRGEC EVQLLESGGGLVQPGGSLRLSCAASGFTFSDNAMG WVRQAPGKGLEW VS AISGPGS STYYAD S VKGRFTIS RDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFDY WGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAAL GCLVEDYFPEPVTVSWNSGALTSGVHTFPAVLQSSG LYSLSSVVTVPSSSLGTQ TYICNVNHKPSNTKVDEK VEPKSCDGGGGSGGGGSQAVVTQEPSLTVSPGGTV TLTCGSSTGAVTTSNYANWVQEKPGQAFRGLIGGT 52 NS ledge Mab22 NKRAPGTPARF SGSLLGGKAALTLLSGAQPEDEAEY YCALWYSNLWVFGGGTKLTVLSSASTKGPSVFPLA PSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTS GVHTFPAVLQSSGLYSLSSVVTVPSSSLGTQTYICNV NHKPSNTKVDKKVEPKSCDKTHTCPPCPAPEAAGG PSVFLFPPKPKDTLM ISRTPEVTCVVVDVSHEDPEV I<FNWYVDGVEVHNAI<TI<PREEQYNSTYRVVSVLT VLHQDWLNGKEYKCKVSNKALGAPIEKTISKAKGQ PREPQVYTLPPCRDELTKNQVSLWCLVKGFYPSDIA VEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVD KSRWQQGNVFSCSVMHEAL HNHYTQKSLSLSPGK

- 28 043592

53 NS depression Mab22 EVQLLESGGGLVQPGGSLRLSCAASGFTFSDNAMG W VRQAPGKGLEWVS AISGPGS STYYAD S VKGRFTIS RDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFDY WGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAAL GCLVEDYFPEPVTVSWNSGALTSGVHTFPAVLQSSG LYSLSSVVTVPSSSLGT QTYICNVNHKPSNTKVDEK VEPKSCDKTHTCPPCPAPEAAGGPSVFLFPPKPKDTL MISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVH NAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEY KCKVSNKALGAPIEKTISKAKGQPREPQVCTLPPSR DELTKNQVSLSCAVKGFYPSDIAVE WESNGQPENN YKTTPPVLDSDGSFFLVSKLTVDKSRWQQGNVFSCS VMHEALHNHYTQKSL SLSPGK 54 LC Mab22 EIVLTQSPGTLSLSPGERATLSCRASQSVSSYYLAWY QQKPGQAPRLLISGAGSRATGIPDRFSGSGGTDFTL TISRLEPEDFAVYYCQQYGYPPDFTFGQGTKVEIKR TVAAPSVFIFPPSDRKLKSGTASVVCLLNNFYPREA KVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTL TLSKADYEK HKVYACEVTHQGLSSPVTKSFNRGEC 55 NS ledge Mab42 EVQLLESGGGLVQPGGSLRLSCAASGFTFSDNAMG WVRQAPGKGLEW VS AISGPGS STYYAD S VKGRFTIS RDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFDY WGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAAL GCLVEDYFPEPVTVSWNSGALTSGVHTFPAVLQSSG LYSLSSVVTVPSSSLGTQ TYICNVNHKPSNTKVDEK VEPKSCDGGGGSGGGGSQAVVTQEPSLTVSPGGTV TLTCGSSTGAVTTSNYANWVQEKPGQAFRGLIGGT NKRAPGTPARF SGSLLGGKAALTLLSGAQPEDEAEY YCALWYSNLWVFGGGTKLTVLSSASTKGPSVFPLA PSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTS GVHTFP AVLQSSGLYSLSSVVTVPSSSLGTQTYICNV NHKPSNTKVDKKVEPKSCDKTHTCPPCPAPEAAGG PSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEV KFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLT VLHQDWLNGKEYKCKVSNKALGAPIEKTISKAKGQ PREPQVYTLP PCRDELTKNQVSLWCLVKGFYPSDIA VEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVD KSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

- 29 043592

56 NS depression Mab42 EVQLLESGGGLVQPGGSLRLSCAASGFTFSDNAMG W VRQ APGKGLEW VS AISGPGS STYYAD S VKGRFTIS RDNSKNTLYLQMNSLRAEDTAVYYCAKVLGWFDY WGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAAL GCLVEDYFPEPVTVSWNSGALTSGVHTFPAVLQSSG L YSLS S WT VP S S SLGTQT YICNVNHKP SNTK VDEK VEPKSCDKTHTCPPCPAPEAAGGPSVFLFPPKPKDTL MISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVH NAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEY KCKVSNKALGAPIEKTISKAKGQPREPQVCTLPPSR DELTKNQVSLSCAV KGFYPSDIAVEWESNGQPENN YKTTPPVLDSDGSFFLVSKLTVDKSRWQQGNVFSCS VMHEALHNHYTQKSLSLSPGK 57 LC Mab42 EIVLTQSPGTLSLSPGERATLSCRASQSVSDEYLSWY QQKPGQAPRLLIHSASTRATGIPDRFSGSGSGTDFTL AISRLEPEDFAVYYCQQYGYPPDFTFGQGTKVEIKR TVAAPSVFIFPPSDRKLKSGTASVVCLLNNFYPREA KVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTL TLSKADYEKHK VYACEVTHQGLSSPVTKSFNRGEC

Note: SEQ ID NO: 20 and SEQ ID NO: 33 are identical

Table 1B. Antibody sequences (short list)

SEQ ID NO: Antibody to CD3 VH VL CDR1H CDR2H CDR3H CDR1L CDR2L CDR3L 7 8 1 2 3 4 5 6 WSMA antibody VH VL CDR1H CDR2H CDR3H CDR1L CDR2L CDR3L 83A10 9 eleven 15 16 17 18 19 20 Mab21 10 12 21 22 17 23 24 20 Mab22 10 13 21 22 17 25 26 20

Table 2A. Additional designs

SEQ ID NO: Fragment/structure 83A10 Mab21 Mab22 Mab42 CHI BCMA 41 41 41 41 CL BCMA 42 42 42 42 CHI CD3 43 43 43 43 CL CD3 44 44 44 44

Table 2B. Additional designs

SEQ ID NO: Design 83A10 Mab21 Mab22 Mab42 BCMA VH CHlcv x CD3 VL CHI Fc lug LALA PG (HC lug) 45 49 52 55 BCMAcv NS hole LALA PG (depression NS) 46 50 53 56 BCMAcv LC human IgGl (BCMA LC) 47 51 54 57 CD3 VH CL (CD3 LC) 48 48 48 48

To create the following (2+1) Fc-containing TSVs to BCMA/CD3, the corresponding constructs/sequence identifiers were used, as indicated in Table. 2B above:

83A10-TCBcv: 45, 46, 47 (x2), 48 (Fig. 2A)

21-TCBcv: 48, 49, 50, 51 (x2) (Fig. 2A)

- 30 043592

22-TCBcv: 48, 52, 53, 54 (x2) (Fig. 2A)

42-TCBcv: 48, 55, 56, 57 (x2) (Fig. 2A)

F. Methods of treatment and prophylaxis and compounds for use in such methods

Compounds 1, 2 and 3 and their enantiomers, mixtures of enantiomers, tautomers, isotopologues or pharmaceutically acceptable salts provided herein in combination with a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3 ) proposed herein can be used in all treatment modalities as proposed herein.

In one embodiment, provided herein is a method of treating multiple myeloma that includes administering to a patient Compound 1 or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and Human CD3ε (CD3) as provided herein are optional, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA) and a second binding moiety that specifically binds to human CD3ε (CD3), with wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, provided herein is a compound for use in a method of treating multiple myeloma, wherein the compound is Compound 1 or an enantiomer thereof, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, wherein the method comprises administering Compound 1 or an enantiomer thereof to a patient, mixtures of enantiomers, tautomers, isotopologues, or pharmaceutically acceptable salts and a bispecific antibody specifically binding to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein, optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binding to human B cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), said first binding portion comprising a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region with SEQ ID NO: 17 and a VL region comprising a CDR3L region with SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, provided herein is a method of treating multiple myeloma that includes administering to a patient Compound 2, a tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3). as provided herein, optionally, wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion contains a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region containing a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions , selected from the group

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, provided herein is a compound for use in a method of treating multiple myeloma, wherein the compound is Compound 2, or a tautomer, isotopologue, or pharmaceutically acceptable salt thereof, the method comprising administering to a patient Compound 2, a tautomer, isotopologue, or pharmaceutically acceptable salt thereof. salt and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3), optionally provided herein, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen ( BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising the CDR1H region of SEQ ID NO: 21, the CDR2H region of SEQ ID NO: 22, and the CDR3H region of SEQ ID NO: 22 ID NO: 17 and a VL region comprising a CDR3L region with SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

- 31 043592

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, provided herein is a method of treating multiple myeloma that includes administering to a patient Compound 3 or a tautomer, isotopologue, or pharmaceutically acceptable salt thereof and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3). as provided herein, optionally, wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion contains a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region containing a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions , selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, provided herein is a compound for use in a method of treating multiple myeloma, wherein the compound is Compound 3 or a tautomer, isotopologue, or pharmaceutically acceptable salt thereof, wherein the method comprises administering Compound 3 or a tautomer, isotopologue, or pharmaceutically acceptable salt thereof to a patient and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3), optionally provided herein, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA). ), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22, and a CDR3H region of SEQ ID NO: 22 NO: 17 and a VL region comprising the CDR3L region of SEQ ID NO: 20 and a combination of the CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO:28.

In one embodiment, provided herein is a method of preventing multiple myeloma, which includes administering to a patient a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt, and a bispecific an antibody comprising a first binding moiety that specifically binds to human B cell maturation antigen (BCMA) and a second binding moiety that specifically binds to human CD3ε (CD3) as provided herein, optionally wherein the bispecific antibody is characterized in that said first binding moiety contains a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region containing a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions , selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, provided herein is a compound for use in a method for preventing multiple myeloma, wherein the compound is a compound provided herein, such as compound 1, compound 2, or compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or a pharmaceutically acceptable salt, the method comprising administering to a patient a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody comprising a first binding moiety specifically binding to human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3) as provided herein, wherein the bispecific antibody is optionally characterized in that said first binding portion comprises a VH region containing a region CDR1H having SEQ ID NO: 21, a CDR2H region having SEQ ID NO: 22 and a CDR3H region having SEQ ID NO: 17 and a VL region comprising a CDR3L region having SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

- 32 043592

In another embodiment, provided herein is a method of treating multiple myeloma, which includes administering to a patient a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, and a bispecific an antibody comprising a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA) and a second binding moiety that specifically binds to human CD3ε (CD3) as provided herein, wherein the bispecific antibody is optionally characterized in that said first the binding portion comprises a VH region containing a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17, and a VL region containing a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L regions and CDR2L selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein is a compound for use in a method of treating multiple myeloma, wherein the compound is a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutical thereof. acceptable salt, the method comprising administering to a patient a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody comprising a first binding moiety specifically binding to human B-cell maturation antigen (BCMA), and a second binding moiety specifically binding to human CD3ε (CD3) as provided herein, wherein the bispecific antibody is optionally characterized in that said first binding moiety comprises a VH region containing a region CDR1H having SEQ ID NO: 21, a CDR2H region having SEQ ID NO: 22 and a CDR3H region having SEQ ID NO: 17, and a VL region comprising a CDR3L region having SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, this document also provides methods for inducing a therapeutic response assessed by the International Uniform Response Criteria for Multiple Myeloma (IURC) (see Durie BGM, Harousseau J-L, Miguel JS, et al. International uniform response criteria for multiple myeloma. Leukemia, 2006;(10)10:1-7) to a patient, comprising administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binds to the antigen human B cell maturation (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22, and a CDR3H region of SEQ ID NO: 17; and a VL region comprising a CDR3L region of SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, this document also provides methods for inducing a therapeutic response assessed using the International Myeloma Working Group (IMWG) consensus criteria for response and minimal residual disease assessment (Rajkumar et al., Blood, 2011, 117(18):4691 -5; Kumar et al., Lancet Oncol, 2016,17(8):e328-e346) to a patient, comprising administering an effective amount of a compound described herein, for example compound 1, compound 2 or compound 3, or an enantiomer thereof, a mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody contains a first binding portion that specifically binds to human B cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region of SEQ ID NO: 21, a CDR2H region with SEQ ID NO: 22 and a CDR3H region with SEQ ID NO: 17 and a VL region containing a CDR3L region with SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, a compound is provided herein for use in methods of inducing a therapeutic response assessed by the International Uniform Response Criteria for Multiple Myeloma (IURC) (see Durie BGM, Harousseau J-L, Miguel JS, et al. International uniform response criteria for multiple myeloma. Leukemia, 2006;(10)10:1-7) in a patient, wherein the compound is a compound provided herein, such as compound 1, compound 2 or compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue or a pharmaceutically acceptable salt, the methods comprising administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof and a bispecific antibody that specifically binds the antigen human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein are optionally required for a patient suffering from multiple myeloma, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22, and a CDR3H region of SEQ ID NO: 17 and a VL region comprising the CDR3L region of SEQ ID NO: 20, and a combination of the CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, this document provides a compound for use in methods for inducing a therapeutic response assessed using the International Myeloma Working Group (IMWG) consensus criteria for response and minimal residual disease assessment (Rajkumar et al, Blood, 2011, 117(18) :4691-5; Kumar et al, Lancet Oncol, 2016,17(8):e328-e346) in a patient, wherein the compound is a compound provided herein, for example compound 1, compound 2 or compound 3, or its enantiomer, mixture of enantiomers, tautomer, isotopologue, or a pharmaceutically acceptable salt thereof, wherein the methods comprise administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: : 22 and a CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein are methods of achieving a strict complete response, a complete response, or a very good partial response, as defined by the International Unified Response Criteria for Multiple Myeloma (IURC) in a patient, comprising administering an effective amount of a compound described herein, e.g. 1, compound 2 or compound 3, or an enantiomer thereof, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein, patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion contains a VH region containing a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region containing a CDR3L region of SEQ ID NO: 20, and a combination of CDR1L and CDR2L selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

- 34 043592

In another embodiment, provided herein are methods for achieving sustained MRD negativity, flow cytometry-based MRD negativity, sequencing-based MRD negativity, imaging plus MRD negativity, stringent complete response, complete response, or very good partial response, as determined by using International Myeloma Working Group (IMWG) consensus criteria to assess response and minimal residual disease in a patient, including administration of an effective amount of a compound described herein, e.g., Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer thereof , an isotopologue or pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety , specifically binding to human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region with SEQ ID NO: 22 and a CDR3H region with SEQ ID NO: 17 and a VL region containing a CDR3L region with SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein is a compound for use in methods of achieving a stringent complete response, a complete response, or a very good partial response as defined by the International Unified Response Criteria for Multiple Myeloma (IURC) in a patient, wherein the compound is a compound provided herein , such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, wherein the methods comprise administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein, to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region with SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein is a compound for use in methods of achieving sustained MRD negativity, flow cytometry-based MRD negativity, sequencing-based MRD negativity, imaging plus MRD negativity, stringent complete response, complete response, or very good partial response, as defined by the International Myeloma Working Group (IMWG) consensus criteria for assessing response and minimal residual disease in a patient, wherein the compound is a compound provided herein, such as compound 1, compound 2, or compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt thereof, the methods comprising administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binds with human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), said first binding portion comprising a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 21 NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

- 35 043592

In another embodiment, provided herein are methods of achieving an increase in overall survival, progression-free survival, event-free survival, time to progression, or disease-free survival in a patient, comprising administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer thereof, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, and a bispecific antibody specifically binding to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein, to a patient suffering from multiple myeloma , optionally, wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22, and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group :

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein is a compound for use in methods of achieving an increase in overall survival, progression-free survival, event-free survival, time to progression or disease-free survival in a patient, wherein the compound is a compound provided herein, for example compound 1, compound 2 or compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, the methods comprising administering an effective amount of a compound described herein, such as compound 1, compound 2, or compound 3, or an enantiomer, a mixture thereof enantiomers, tautomer, isotopologue or pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding a portion that specifically binds to human B-cell maturation antigen (BCMA), and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region of SEQ ID NO: 21, region CDR2H having SEQ ID NO: 22 and a CDR3H region having SEQ ID NO: 17 and a VL region containing a CDR3L region having SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein are methods of achieving an increase in overall survival in a patient, comprising administering an effective amount of a compound described herein, for example, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binds to the antigen human B cell maturation (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein is a compound for use in methods for achieving increased overall survival in a patient, wherein the compound is a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, isotopologue or pharmaceutically acceptable salt, the methods comprising administering an effective amount of a compound described herein, such as Compound 1, Compound 2 or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue or pharmaceutically acceptable salt and a bispecific antibody that specifically binds with human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein is optionally required for a patient suffering from multiple myeloma, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA). ), and a second connecting part,

- 36 043592 specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising the CDR1H region of SEQ ID NO: 21, the CDR2H region of SEQ ID NO: 22, and the CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein are methods of achieving increased progression-free survival in a patient, comprising administering an effective amount of a compound described herein, for example, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically thereof. acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: : 22 and a CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein is a compound for use in methods of achieving increased progression-free survival in a patient, wherein the compound is a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer thereof , isotopologue, or pharmaceutically acceptable salt, the methods comprising administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody, specifically binding to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein in a patient suffering from multiple myeloma is optional, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen ( BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22, and a CDR3H region of SEQ ID NO: 22 ID NO: 17 and a VL region containing the CDR3L region of SEQ ID NO: 20, and a combination of the CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24 ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26 or iii) the CDR1L region of SEQ ID NO: 27 and CDR2L region with SEQ ID NO: 28.

In another embodiment, provided herein are methods of achieving increased event-free survival in a patient, comprising administering an effective amount of a compound described herein, for example, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically thereof. acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: : 22 and a CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein is a compound for use in methods of achieving increased event-free survival in a patient, wherein the compound is a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer thereof , isotopologue, or pharmaceutically acceptable salt, the methods comprising administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer thereof, a mixture

- 37 043592 enantiomers, tautomers, isotopologues or pharmaceutically acceptable salts and bispecific antibodies specifically binding to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising the CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22, and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein are methods of achieving an increase in time to progression in a patient, comprising administering an effective amount of a compound described herein, for example, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically thereof. acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: : 22 and a CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein is a compound for use in methods of achieving an increase in time to progression in a patient, wherein the compound is a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer thereof , isotopologue, or pharmaceutically acceptable salt, the methods comprising administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody, specifically binding to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein in a patient suffering from multiple myeloma is optional, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen ( BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22, and a CDR3H region of SEQ ID NO: 22 ID NO: 17 and a VL region containing the CDR3L region of SEQ ID NO: 20, and a combination of the CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or ii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, provided herein are methods of achieving increased disease-free survival in a patient, comprising administering an effective amount of a compound described herein, for example, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically thereof. acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: : 22 and a CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, this document provides a compound for use in

- 38 043592 methods of achieving increased disease-free survival in a patient, wherein the compound is a compound as provided herein, for example compound 1, compound 2 or compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue or pharmaceutically acceptable salt thereof, wherein the methods involve administering an effective amount of a compound described herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B cell maturation antigen ( BCMA) and human CD3ε (CD3) provided herein to a patient suffering from multiple myeloma optionally, wherein the bispecific antibody comprises a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA) and a second binding moiety that specifically binds binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region containing a CDR3L region with SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

This document also provides methods for treating patients previously treated for multiple myeloma who have not responded to standard therapeutic agents, as well as treatment-naïve patients. Also included are methods of treating patients who have undergone surgery for the treatment of multiple myeloma, as well as patients who have not undergone surgery. This document also proposes treatments for patients who have previously undergone organ transplantation, as well as patients who have not previously undergone such treatment. This document also provides a compound for use in methods of treating patients previously treated for multiple myeloma who have not responded to standard therapeutic agents, as well as treatment-naïve patients. Also included is a compound for use in methods of treating patients who have undergone surgery for the treatment of multiple myeloma, as well as patients who have not undergone surgery. This document also provides a compound for use in methods of treating patients who have previously undergone organ transplantation, as well as patients who have not previously undergone such treatment.

The methods provided herein include the treatment of multiple myeloma that is relapsed, refractory or refractory. Methods provided herein include the prevention of multiple myeloma that is relapsed, refractory or refractory. Methods provided herein include the control of multiple myeloma that is relapsed, refractory or refractory. In some such embodiments, the myeloma is single-, double-, triple-, quadruple-, or quintuple-relapsed multiple myeloma. The methods provided herein include the treatment of multiple myeloma, which is newly diagnosed multiple myeloma (including newly diagnosed low, intermediate and high risk multiple myeloma). The methods provided herein include the prevention of multiple myeloma, which is newly diagnosed multiple myeloma (including newly diagnosed low-, intermediate-, and high-risk multiple myeloma). The methods proposed herein include interventions to combat multiple myeloma, which is newly diagnosed multiple myeloma (including newly diagnosed low-risk, intermediate-risk and high-risk multiple myeloma). In one embodiment, the methods provided herein reduce, maintain or eliminate minimal residual disease (MRD). In one embodiment, the methods provided herein include the treatment, prevention or control of various types of multiple myeloma, such as monoclonal gammopathy of unknown origin (MGUS); low-risk, intermediate-risk and high-risk multiple myeloma; multiple myeloma with and without the possibility of transplantation; smoldering (slowly progressive) multiple myeloma (including low-risk, intermediate-risk and high-risk smoldering multiple myeloma); active multiple myeloma; solitary plasmacytoma; extramedullary plasmacytoma; plasma cell leukemia; multiple myeloma of the central nervous system; light chain myeloma; nonsecretory myeloma; immunoglobulin D myeloma; and immunoglobulin E myeloma, by administering a therapeutically effective amount of a compound described herein. In one embodiment, multiple myeloma is a plasma cell leukemia. In another embodiment, the methods provided herein include the treatment, prevention or control of multiple myeloma characterized by genetic abnormalities such as cyclin D translocation (e.g., t(11;14)(q13;q32); t(6;14) (p21;32); t(12;14)(p13;q32); or t(6;20);); MMSET translocations (e.g.

- 39 043592 t(4;14)(p16;q32)); MAF translocations (e.g. t(14;16)(q32;q32); t(20;22); t(16; 22)(q11;q13); or t(14;20)(q32;q11)); or other chromosomal factors (eg, deletion of 17p13, or chromosome 13; del(17/17p), non-hyperploidy and gain(1q)), by administering a therapeutically effective amount of a compound described herein. In one embodiment, the methods include administering a therapeutically effective amount of Compound 1 or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) as disclosed herein. herein, optionally, the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a region VH comprising the CDR1H region of SEQ ID NO: 21, the CDR2H region of SEQ ID NO: 22 and the CDR3H region of SEQ ID NO: 17 and the VL region containing the CDR3L region of SEQ ID NO: 20 and a combination of the CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, the methods comprise administering a therapeutically effective amount of Compound 2, a tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein, optionally wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region with SEQ ID NO: 21, a CDR2H region with SEQ ID NO: 22 and a CDR3H region with SEQ ID NO: 17 and a VL region containing a CDR3L region with SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In another embodiment, the methods include administering a therapeutically effective amount of Compound 3, a tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3), optionally provided herein wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region with SEQ ID NO: 21, a CDR2H region with SEQ ID NO: 22 and a CDR3H region with SEQ ID NO: 17 and a VL region containing a CDR3L region with SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, high-risk multiple myeloma is multiple myeloma that has relapsed within 12 months of the first course of treatment. In yet another embodiment, high-risk multiple myeloma is multiple myeloma that is characterized by genetic abnormalities, such as one or more of del(17/17p) and t(14;16)(q32;q32).

In some such embodiments, the multiple myeloma is a newly diagnosed transplantable multiple myeloma. In another embodiment, the multiple myeloma is newly diagnosed multiple myeloma without the possibility of transplantation. In yet other embodiments, multiple myeloma is characterized by early progression (eg, less than 12 months) after initial treatment. In yet other embodiments, multiple myeloma is characterized by early progression (eg, less than 12 months) after autologous stem cell transplantation. In another embodiment, the multiple myeloma is refractory or resistant to lenalidomide. In another embodiment, multiple myeloma is refractory to lenalidomide. In another embodiment, the multiple myeloma is resistant to lenalidomide. In another embodiment, the multiple myeloma is refractory or resistant to pomalidomide. In another embodiment, multiple myeloma is refractory to pomalidomide. In another embodiment, the multiple myeloma is resistant to pomalidomide. In some such embodiments, multiple myeloma is predicted to be refractory to

- 40 043592 pomalidomide (for example, molecular characteristics). In another embodiment, the multiple myeloma is relapsed or refractory to 3 or more treatments and has been exposed to a proteasome inhibitor (eg, bortezomib, carfilzomib, ixazomib, oprosomib, or marizomib) and an immunomodulatory compound (eg, thalidomide, lenalidomide, pomalidomide CC122 or CC220), or dual refractory to a proteasome inhibitor and an immunomodulatory compound. In subsequent other embodiments, the multiple myeloma is relapsed or refractory to 3 or more treatments, including, for example, a CD38 monoclonal antibody (CD38 mAb, e.g., daratumumab or isatuximab), a proteasome inhibitor (e.g., bortezomib, carfilzomib, ixazomib, or marizomib), and an immunomodulatory compound (eg, thalidomide, lenalidomide, pomalidomide CC122 or CC220), or dual refractory to a proteasome inhibitor or immunomodulatory compound and a CD38 mAb. In subsequent other embodiments, the multiple myeloma is triple refractory, for example, the multiple myeloma is refractory to a proteasome inhibitor (e.g., bortezomib, carfilzomib, ixazomib, oprosomib, or marizomib) and an immunomodulatory compound (e.g., thalidomide, lenalidomide, pomalidomide CC122 or CC220) and one another active agent as described herein.

In some embodiments, provided herein are methods of treating, preventing, and/or controlling multiple myeloma, including relapsed/refractory multiple myeloma in patients with impaired renal function, or symptoms thereof, comprising administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein, to a patient suffering from relapsed/refractory multiple myeloma with renal impairment, optionally, wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region containing a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions , selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In some embodiments, provided herein is a compound for use in methods of treating, preventing, and/or controlling multiple myeloma, including relapsed/refractory multiple myeloma in patients with impaired renal function, or symptoms thereof, wherein the compound is a compound provided herein , for example, Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, wherein the methods include administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, isotopologue, or pharmaceutically acceptable salt and a bispecific antibody specifically binding to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a patient suffering from relapsed/refractory multiple myeloma with renal impairment, optionally, wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region with SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In some embodiments, provided herein are methods of treating, preventing, and/or controlling multiple myeloma, including relapsed or refractory multiple myeloma in debilitated patients, or symptoms thereof, comprising administering a therapeutically effective amount of compound 1, compound 2, or compound 3, or an enantiomer thereof , a mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein, to a debilitated patient suffering from multiple myeloma, optionally, wherein bispecific antibody contains the first binding

- 41 043592 a portion specifically binding to human B-cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region of SEQ ID NO: 21, CDR2H region with

SEQ ID NO: 22 and the CDR3H region of SEQ ID NO: 17 and the VL region containing the CDR3L region of SEQ ID

NO: 20, and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In some embodiments, provided herein is a compound for use in methods of treating, preventing, and/or controlling multiple myeloma, including relapsed or refractory multiple myeloma in debilitated patients, or symptoms thereof, wherein the compound is a compound provided herein, e.g. 1, compound 2 or compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, the methods comprising administering a therapeutically effective amount of compound 1, compound 2, or compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue thereof or a pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein to a debilitated patient suffering from multiple myeloma, optionally, wherein the bispecific antibody comprises a first binding moiety, specifically binding to human B cell maturation antigen (BCMA), and a second binding portion specifically binding to human CD3ε (CD3), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and CDR2L region with SEQ ID NO: 28.

In some such embodiments, the debilitated patient is characterized by failure of induction therapy or intolerance to dexamethasone treatment. In some such embodiments, the frail patient is of advanced age, such as over 65 years of age.

In some embodiments, the patient to be treated with one of the methods provided herein has not received therapy against multiple myeloma prior to administration of Compound 1, Compound 2, or Compound 3 provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or a pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein. In some embodiments, a patient to be treated with one of the methods provided herein has undergone therapy against multiple myeloma prior to administration of Compound 1, Compound 2, or Compound 3 provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutical thereof. an acceptable salt and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein.

In some embodiments, a patient being treated with one of the methods provided herein has developed drug resistance to multiple myeloma therapy. In some such embodiments, the patient has developed resistance to one, two, three, four, five, or more multiple myeloma therapeutic agents. In one embodiment, the therapeutic agents are selected from an anti-CD38 monoclonal antibody (anti-CD38 mAb, e.g., daratumumab or isatuximab), a proteasome inhibitor (e.g., bortezomib, carfilzomib, ixazomib, or marizomib), and an immunomodulatory compound (e.g., thalidomide, lenalidomide, pomalidomide, CC122 or CC220). In one embodiment, the therapeutic agents include one or more of an anti-CD38 monoclonal antibody (anti-CD38 mAb, e.g., daratumumab or isatuximab), a proteasome inhibitor (e.g., bortezomib, carfilzomib, ixazomib, or marizomib), and an immunomodulatory compound (e.g., thalidomide, lenalidomide , pomalidomide, CC122 or CC220). In one embodiment, the therapeutic agents include one or more alkylating agents (e.g., melphalan, cyclophosphamide, bendamustine), histone deacetylase inhibitors (e.g., panobinostat), other monoclonal antibodies (e.g., anti-SLAMF7 antibody, e.g., elotuzumab), glucocorticoids (e.g., dexamethasone, prednisone), other multiple myeloma therapeutics (eg, cisplatin, eotoposide, doxorubicin), and cell-based therapeutics (eg, CAR-T).

The methods proposed herein include treatment of a patient, regardless of the age of the patient. In some embodiments, the subject is an 18-year-old subject or

- 42 043592 older. In other embodiments, the subject's age is greater than 18, 25, 35, 40, 45, 50, 55, 60, 65, or 70 years. In other embodiments, the subject is at least 65 years of age. In other embodiments, the subject is no more than 65 years of age. In one embodiment, the subject is an elderly subject with multiple myeloma, such as a subject over 65 years of age. In one embodiment, the subject is an elderly subject with multiple myeloma, such as a subject over 75 years of age.

G. Dosing of Compound 1, Compound 2 or Compound 3

In some embodiments, the therapeutically or prophylactically effective amount of the compound is from about 0.01 to about 25 mg per day, from about 0.01 to about 10 mg per day, from about 0.01 to about 5 mg per day, about 0 .01 to about 2 mg per day, from about 0.01 to about 1 mg per day, from about 0.01 to about 0.5 mg per day, from about 0.01 to about 0.25 mg per day, from about 0.1 to about 25 mg per day, about 0.1 to about 10 mg per day, about 0.1 to about 5 mg per day, about 0.1 to about 2 mg per day, about 0 .1 to about 1 mg per day, about 0.1 to about 0.5 mg per day, about 0.1 to about 0.25 mg per day, about 0.5 to about 25 mg per day, from about 0.5 to about 10 mg per day, about 0.5 to about 5 mg per day, about 0.5 to about 2 mg per day, about 0.5 to about 1 mg per day, about 1 up to about 25 mg per day, about 1 to about 10 mg per day, about 1 to about 5 mg per day, about 1 to about 2.5 mg per day, or about 1 to about 2 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.01 to about 25 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.01 to about 10 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.01 to about 5 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.01 to about 2 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.01 to about 1 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.01 to about 0.5 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.01 to about 0.25 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.1 to about 25 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.1 to about 10 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.1 to about 5 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.1 to about 2 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.1 to about 1 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.1 to about 0.5 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.1 to about 0.25 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.5 to about 25 mg per day. In one embodiment, a therapeutically or prophylactically effective amount of a compound is from about 0.5 to about 10 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.5 to about 5 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.5 to about 2 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 0.5 to about 1 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 1 to about 25 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 1 to about 10 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 1 to about 5 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 1 to about 2.5 mg per day. In one embodiment, the therapeutically or prophylactically effective amount of the compound is from about 1 to about 2 mg per day. In one embodiment, a therapeutically or prophylactically effective amount of Compound 1, Compound 2, or Compound 3 is from about 0.1 mg per day to about 0.4 mg per day.

In some embodiments, the therapeutically or prophylactically effective amount is about 0.1, about 0.2, about 0.3, about 0.4, about 0.5, about 0.6, about 0.7, about 0.8 , about 0.9, about 1, about 2, about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10, about 15, about 20 or about 25 mg per day. In some such embodiments, the therapeutically or prophylactically effective amount is about 0.1, about 0.2, about 0.3, about 0.4, about 0.5, about 0.6, or about 0.7 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 0.1 mg per day. In some

- 43 043592 embodiments, the therapeutically or prophylactically effective amount is about 0.2 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 0.3 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 0.4 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 0.5 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 0.6 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 0.7 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 0.8 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 0.9 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 1 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 2 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 3 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 4 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 5 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 6 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 7 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 8 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 9 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 10 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 15 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 20 mg per day. In some embodiments, the therapeutically or prophylactically effective amount is about 25 mg per day.

In one embodiment, the recommended daily dosage range of Compound 1, Compound 2, or Compound 3, or an enantiomer thereof, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt thereof under the conditions described herein is in the range of about 0.1 mg up to about 25 mg per day, in one embodiment, as a single dose once daily or in divided doses throughout the day. In other embodiments, dosage ranges are from about 0.1 to about 10 mg per day. Specific doses per day include 0.1, 0.2, 0.3, 0.4, 0.5, 1,2,3,4,5,6,7,8,9, 10, 11, 12, 13 , 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 or 25 mg per day. More specific dosages per day include 0.1, 0.2, 0.3, 0.4, or 0.5 mg per day. In one embodiment, the specific dose per day is 0.1 mg per day. In one embodiment, the specific dosage per day is 0.2 mg per day. In one embodiment, the specific dosage per day is 0.3 mg per day. In one embodiment, the specific dosage per day is 0.4 mg per day. In one embodiment, the specific dose per day is 0.5 mg per day. In one embodiment, the specific dosage per day is 1 mg per day. In one embodiment, the specific dosage per day is 2 mg per day. In one embodiment, the specific dosage per day is 3 mg per day. In one embodiment, the specific dosage per day is 4 mg per day. In one embodiment, the specific dosage per day is 5 mg per day. In one embodiment, the specific dosage per day is 6 mg per day. In one embodiment, the specific dosage per day is 7 mg per day. In one embodiment, the specific dosage per day is 8 mg per day. In one embodiment, the specific dosage per day is 9 mg per day. In one embodiment, the specific dosage per day is 10 mg per day. In one embodiment, the specific dose per day is 11 mg per day. In one embodiment, the specific dosage per day is 12 mg per day. In one embodiment, the specific dosage per day is 13 mg per day. In one embodiment, the specific dosage per day is 14 mg per day. In one embodiment, the specific dosage per day is 15 mg per day. In one embodiment, the specific dosage per day is 16 mg per day. In one embodiment, the specific dosage per day is 17 mg per day. In one embodiment, the specific dosage per day is 18 mg per day. In one embodiment, the specific dosage per day is 19 mg per day. In one embodiment, the specific dosage per day is 20 mg per day. In one embodiment, the specific dosage per day is 21 mg per day. In one embodiment, the specific dosage per day is 22 mg per day. In one embodiment, the specific dosage per day is 23 mg per day. In one embodiment, the specific dosage per day is 24 mg per day. In one embodiment, the specific dose per day is 25 mg per day.

In a particular embodiment, the recommended starting dose may be 0.1, 0.2, 0.3, 0.4, 0.5, 1, 2, 3, 4, 5, 10, 15, 20, or 25 mg per day. In another embodiment, the recommended starting dose may be 0.1, 0.2, 0.3, 0.4, or 0.5 mg per day. The dose can be increased to 1, 2, 3, 4 or mg per day.

In specific embodiments, the therapeutically or prophylactically effective amount is from about 0.001 to about 5 mg/kg/day, from about 0.001 to about 4 mg/kg/day, from about 0.001 to about 3 mg/kg/day, from about 0.001 to about 2 mg/kg/day, about 0.001 to about 1 mg/kg/day, 0.001 to about 0.05 mg/kg/day, about 0.001 to about 0.04 mg/kg/day, about 0.001 to about 0.03 mg/kg/day, about 0.001 to about 0.02 mg/kg/day, about 0.001 to about 0.01 mg/kg/day, or about 0.001 to about 0.005 mg/kg/day.

The administered dose may also be expressed in units other than mg/kg/day. For example, doses for parenteral administration may be expressed in mg/m ² /day. One skilled in the art will readily determine how to convert doses from mg/kg/day to mg/ ^m2 /day based on the subject's height or weight, or both (see www.fda.gov/cder/cancer/animalframe.htm) . For example, a dose of 1 mg/kg/day for a 65 kg person is approximately 38 mg/ ^m2 /day.

Depending on the condition of the disease being treated and the condition of the subject, Compound 1, Compound 2, or Compound 3 provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, can be administered by an oral, parenteral route (eg , intramuscular, intraperitoneal, intravenous, IV, intracisternal injection or infusion, subcutaneous injection or implant), by inhalation, nasal, vaginal, rectal, sublingual or topical (eg, transdermal or topical) route of administration. Compound 1, Compound 2 or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue or pharmaceutically acceptable salt thereof may be formulated, alone or together, into a suitable unit dosage form with pharmaceutically acceptable excipients, carriers, adjuvants and liquid media suitable for each route of administration.

In one embodiment, Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, is administered orally. In another embodiment, Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, is administered parenterally. In yet another embodiment, Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof is administered intravenously.

Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, can be delivered in a single dose, such as, for example, a single bolus injection or oral tablets or pills; or over a specified period of time, for example, by continuous infusion over a specified time or in divided bolus doses over a specified time. The compounds described herein may be administered multiple times as necessary, for example, until the patient's disease is stabilized or regressed, or until the patient experiences disease progression or unacceptable toxicity. Stable disease or absence thereof is determined by methods known in the art, such as assessment of the patient's symptoms, physical examination, laboratory tests, imaging of the tumor by X-ray, CT, PET or MRI, and other conventional methods. assessments.

In one embodiment of the methods provided herein, a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof is administered to a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and with human CD3ε (CD3) proposed herein. In one embodiment of the methods provided herein, a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, concurrently with a bispecific antibody that specifically binds human B-cell maturation antigen (BCMA) and with human CD3ε (CD3) proposed herein. In one embodiment of the methods provided herein, a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof is administered after a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and with human CD3ε (CD3) proposed herein.

Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, may be independently administered once daily (QD) or may be divided into multiple daily doses, such as for dosing twice daily (BID), three times daily (TID and four times daily (QID). In addition, administration can be continuous (i.e., daily for several days or every day) , periodically, for example, in cycles (i.e., including days, weeks or months of rest without drug).As used herein, the term daily means that a therapeutic compound, such as compound 1, compound 2 or compound 3 as provided herein, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt thereof is administered one or more times per day, for example, over a period of time.The term continuous means that the therapeutic compound, such as Compound 1, Compound 2 or compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, is administered daily for a continuous period of at least 7 days to 52 weeks. The term periodic or periodic as used herein means stopping and starting at regular or irregular intervals. For example, periodic administration of Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, is administration for one to six days per week, administration in cycles (e.g. , daily administration for two to eight consecutive weeks, followed by a rest period without administration for up to one week) or administration every other day. As used herein, the term cyclic means that a therapeutic compound, such as Compound 1, Compound 2, or Compound 3 provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof is administered daily or continuously, but with rest period. In some such embodiments, administration is performed once daily for two to six days, followed by a rest period without administration for five to seven days.

In some embodiments, the frequency of administration ranges from about a daily dose to a monthly dose. In specific embodiments, administration is once daily, twice daily, three times daily, four times daily, once daily, twice weekly, once weekly, once every two weeks, once every three weeks or once every four weeks. In one embodiment, Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, is administered once daily. In another embodiment, Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, is administered twice daily. In yet another embodiment, Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, is administered three times daily. In yet another embodiment, Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, is administered four times daily.

In one embodiment, a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 is administered in a treatment cycle that includes an administration period of no more than 20 days, followed by a rest period. In one embodiment, a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 is administered in a treatment cycle that includes an administration period of no more than 15 days, followed by a rest period. In one embodiment, a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 is administered in a treatment cycle that includes an administration period of no more than 10 days, followed by a rest period. In one embodiment, a therapeutically effective amount of compound 1,

Compound 2 or Compound 3 is administered in a treatment cycle that includes an administration period of no more than 7 days, followed by a rest period. In one embodiment, a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 is administered in a treatment cycle that includes an administration period of no more than 5 days, followed by a rest period. In one embodiment, a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 is administered in a treatment cycle that includes an administration period of no more than 4 days, followed by a rest period. In one embodiment, a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 is administered in a treatment cycle that includes an administration period of no more than 3 days, followed by a rest period.

In one embodiment, the treatment cycle includes an administration period of no more than 14 days, followed by a rest period. In one embodiment, the treatment cycle includes an administration period of no more than 10 days, followed by a rest period. In one embodiment, the treatment cycle includes an administration period of no more than 7 days, followed by a rest period. In one embodiment, the treatment cycle includes an administration period of no more than 5 days, followed by a rest period. In one embodiment, the treatment cycle includes an administration period of no more than 4 days, followed by a rest period. In one embodiment, the treatment cycle includes an administration period of no more than 3 days, followed by a rest period.

- 46 043592

In one embodiment, the rest period is from about 2 days to about 11 days. In one embodiment, the rest period is from about 2 days to about 10 days. In one embodiment, the rest period is about 2 days. In one embodiment, the rest period is about 3 days. In one embodiment, the rest period is about 4 days. In one embodiment, the rest period is about 5 days. In one embodiment, the rest period is about 6 days. In another embodiment, the rest period is about 7 days. In another embodiment, the rest period is about 8 days. In another embodiment, the rest period is about 9 days. In another embodiment, the rest period is about 10 days. In another embodiment, the rest period is about 11 days.

In one embodiment, the treatment cycle includes an administration period of no more than 15 days, followed by a rest period of about 2 days to about 10 days. In one embodiment, the treatment cycle includes an administration period of no more than 10 days, followed by a rest period of about 2 days to about 10 days. In one embodiment, the treatment cycle includes an administration period of no more than 7 days, followed by a rest period of about 2 days to about 10 days. In one embodiment, the treatment cycle includes an administration period of no more than 5 days, followed by a rest period of about 2 days to about 10 days. In one embodiment, the treatment cycle includes an administration period of no more than 3 days, followed by a rest period of about 10 days to about 15 days. In one embodiment, the treatment cycle includes an administration period of no more than 3 days, followed by a rest period of about 3 days to about 15 days.

In one embodiment, the treatment cycle includes an administration period of no more than 15 days, followed by a rest period of 7 days. In one embodiment, the treatment cycle includes an administration period of no more than 10 days, followed by a rest period of 5 days. In one embodiment, the treatment cycle includes an administration period of no more than 10 days, followed by a rest period of 4 days. In one embodiment, the treatment cycle includes an administration period of no more than 10 days, followed by a rest period of 3 days. In one embodiment, the treatment cycle includes an administration period of no more than 10 days, followed by a rest period of 2 days. In one embodiment, the treatment cycle includes an administration period of no more than 7 days, followed by a rest period of 7 days. In one embodiment, the treatment cycle includes an administration period of no more than 5 days, followed by a rest period of 5 days. In one embodiment, the treatment cycle includes an administration period of no more than 3 days, followed by a rest period of 11 days. In another embodiment, the treatment cycle includes an administration period of no more than 5 days, followed by a rest period of 9 days. In another embodiment, the treatment cycle includes an administration period of no more than 5 days, followed by a rest period of 2 days. In another embodiment, the treatment cycle includes an administration period of no more than 3 days, followed by a rest period of 4 days.

In one embodiment, the treatment cycle includes administration of a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-5 of a 28-day cycle. In another embodiment, a treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 on days 1-10 of a 28-day cycle. In one embodiment, the treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-21 of a 28-day cycle. In another embodiment, a treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-5 of a 7-day cycle. In another embodiment, a treatment cycle comprises administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-7 of a 7-day cycle. In one embodiment, a treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-10 and days 15-24 of a 28-day cycle. In one embodiment, a treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-3 and days 15-18 of a 28-day cycle. In one embodiment, a treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-7 and days 15-21 of a 28-day cycle. In one embodiment, the treatment cycle includes administration of a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-5 and days 1519 of a 28-day cycle. In one embodiment, the treatment cycle includes administration of a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-3 and days 15-17 of a 28-day cycle.

In one embodiment, the treatment cycle includes administration of a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-14 of a 21-day cycle. In another embodiment, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 on days 1-4 and 8-11 of a 21-day cycle. In one embodiment, the treatment cycle includes administering

- 47 043592 a therapeutically effective amount of compound 1, compound 2 or compound 3 on days 1-5 and 8-12 of a 21-day cycle. In another embodiment, a treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-5 and 11-15 of a 21-day cycle. In another embodiment, a treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-5 and 8-12 and 15-19 of a 21-day cycle. In another embodiment, a treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-4 and 8-11 and 15-18 of a 21-day cycle. In another embodiment, a treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-4 and 8-10 and 15-17 of a 21-day cycle. In another embodiment, a treatment cycle includes administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-3 and 8-11 of a 21-day cycle. In another embodiment, a treatment cycle comprises administering a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 on days 1-3 and 11-13 of a 21-day cycle.

Any treatment cycle described herein may be repeated for a number of cycles of at least 2, 3, 4, 5, 6, 7, 8 or more. In some cases, the treatment cycle described herein includes from 1 to about 24 cycles, from about 2 to about 16 cycles, or from about 2 to about 4 cycles. In some cases, the treatment cycle described herein includes from 1 to about 4 cycles. In some embodiments, cycles 1-4 are all 28-day cycles. In some embodiments, a therapeutically effective amount of Compound 1, Compound 2, or Compound 3 is administered over 1 to 13 cycles of 28 days (eg, over about 1 year). In some cases, cyclic therapy is not limited by the number of cycles, and therapy is continued until the disease progresses. Cycles in some cases may include varying lengths of administration periods and/or rest periods described herein.

In one embodiment, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 at dosage levels of about 0.1 mg/day, 0.2 mg/day, 0.3 mg/day, 0.4 mg/day, 0.5 mg/day, 0.6 mg/day, 0.7 mg/day, 0.8 mg/day, 0.9 mg/day, 1.0 mg/day, 5.0 mg/day or 10 mg/day, when administered once daily. In one embodiment, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 at dosage levels of about 0.1 mg/day, 0.2 mg/day, 0.3 mg/day, 0.4 mg/day, 0.5 mg/day, 0.6 mg/day, 0.7 mg/day, or 0.8 mg/day, administered once daily. In some such embodiments, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 times daily at a dosage level of about 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, or 0.5 mg. , on days 1-10 of a 28-day cycle. In some such embodiments, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 times daily at a dosage level of about 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, or 0.5 mg. , on days 1-10 and 15-24 of a 28-day cycle. In some such embodiments, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 times daily at a dosage level of about 0.1 mg on days 1-10 and 15-24 of a 28-day cycle. In other embodiments, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 twice daily at a dosage level of about 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, or 0.5 mg, on days 1-3 of a 28-day cycle. In other embodiments, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 twice daily at a dosage level of about 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, or 0.5 mg, on days 1-3 and 15-19 of a 28-day cycle. In other embodiments, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 twice daily at a dosage level of about 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, or 0.5 mg, on days 1-3 and 15-17 of a 28-day cycle. In other embodiments, the treatment cycle includes administration of Compound 1, Compound 2, or Compound 3 twice daily at a dosage level of about 0.2 mg on days 1-3 and 15-17 of a 28-day cycle. In one such embodiment, the compound is administered on days 1 to 3 (morning and evening), day 14 (evening only), days 15 and 16 (morning and evening), and day 17 (morning only) in Cycle 1.

H. Dosing of a bispecific antibody that specifically binds to BCMA and CD3

In one embodiment, the bispecific antibody is administered once or twice a week, in one embodiment by subcutaneous administration (e.g., in one embodiment at a dose range of 0.1 to 2.5, in one embodiment up to 25 mg/m ² /week, in one embodiment option up to 250 mg/ ^m2 /week). Because of the superior cytotoxicity of bispecific antibodies, they can be administered in at least the same clinical dose range (or even lower) compared to conventional monospecific antibodies or conventional bispecific antibodies that are not bispecific to T cells (i.e. do not bind to CD3 on one arm). For bispecific antibodies, subcutaneous administration is believed to be preferable in a clinical setting (eg, in the dose range of 0.1-250 mg/m ² /week). Additionally, patients with high serum levels of APRIL and BAFF (eg, patients with multiple myeloma) may not require an increase in the dose of the bispecific antibody because it may not be affected by ligand competition. Conversely, dosages of other ligand-blocking/competing anti-BCMA antibodies may need to be increased in these patients. Another advantage of the bispecific antibody is its half-life of 4 to 12 days, which allows administration at least

- 48 043592 re once or twice a week.

In one embodiment, the bispecific antibody is an antibody having properties that allow treatment once/twice per week by intravenous route, but in one embodiment by subcutaneous administration (e.g., dosage in the range of 200-2000 mg/m ² /week for 4 weeks). It is believed that for bispecific antibodies, subcutaneous administration is possible and preferable in a clinical setting (eg, in the dose range of 200-2000 mg/m ² /week, depending on the disease indication). Additionally, patients with high serum levels of APRIL and BAFF (eg, patients with multiple myeloma) may not require an increase in the dose of the bispecific antibody (eg, non-ligand-blocking/competing antibody) because it may not be affected by ligand competition. In contrast, these patients may require increased doses of other ligand-blocking/competing anti-BCMA antibodies, making subcutaneous administration technically (eg, pharmaceutically) more challenging. Another advantage of bispecific antibodies is based on the inclusion of an Fc portion, which is associated with a half-life of 4 to 12 days and allows for administration at least once or twice a week.

I. Combination therapy with an additional active agent

Treatment with Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or a pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein may also be combined with or used in combination with (e.g., before, during, or after) conventional therapy, including, but not limited to, surgery, biological therapy (including immunotherapy, e.g. checkpoint inhibitors), radiation therapy, chemotherapy, stem cell transplantation, cell therapy, or other non-drug therapy currently used to treat, prevent, or control multiple myeloma. The combined use of a compound provided herein and conventional therapy may provide a unique treatment regimen that is unexpectedly effective in some patients. Without being limited by theory, it is believed that treatment with Compound 1, Compound 2, or Compound 3 and the bispecific antibody specifically binding to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein may provide additive or synergistic effects in simultaneous use with traditional therapy.

As described herein, a method is provided for reducing, treating and/or preventing adverse or unwanted effects associated with conventional therapy, including, but not limited to, surgery, chemotherapy, radiation therapy, biological therapy and immunotherapy. A compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B Cell Maturation Antigen (BCMA) and human CD3ε ( CD3) as provided herein, and the additional active ingredient may be administered to a patient before, during, or after the occurrence of an adverse effect associated with conventional therapy.

Compound 1, Compound 2, or Compound 3 as provided herein, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3 ) proposed herein may also be combined or used in combination with additional therapeutic agents useful for the treatment and/or prevention of multiple myeloma described herein.

In one embodiment, provided herein is a method of treating multiple myeloma, comprising administering to a patient Compound 1 or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and CD3ε human (CD3) as provided herein, in combination with an additional active agent. In one embodiment, provided herein is a method for the prevention of multiple myeloma, comprising administering to a patient Compound 1 or an enantiomer thereof, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and CD3ε human (CD3) as provided herein, in combination with an additional active agent. In one embodiment, provided herein is a method of controlling multiple myeloma, comprising administering to a patient Compound 1 or an enantiomer thereof, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and CD3ε human (CD3) as provided herein, in combination with an additional active agent. In one embodiment, this document

- 49 043592 ment, a method of treating multiple myeloma is proposed, comprising administering to a patient Compound 2 or a tautomer, isotopologue, or pharmaceutically acceptable salt thereof and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) proposed herein document, in combination with an additional active agent. In one embodiment, provided herein is a method for the prevention of multiple myeloma, comprising administering to a patient Compound 2 its tautomer, isotopologue, or pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein. document, in combination with an additional active agent. In one embodiment, provided herein is a method of controlling multiple myeloma, comprising administering to a patient Compound 2, or a tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3), proposed herein, in combination with an additional active agent. In one embodiment, provided herein is a method of treating multiple myeloma, comprising administering to a patient Compound 3, or a tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) as disclosed in herein, in combination with an additional active agent. In one embodiment, provided herein is a method for the prevention of multiple myeloma, comprising administering to a patient Compound 3 its tautomer, isotopologue, or pharmaceutically acceptable salt, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as disclosed herein. herein, in combination with an additional active agent. In one embodiment, provided herein is a method of controlling multiple myeloma, comprising administering to a patient Compound 3 or a tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) as disclosed in herein, in combination with an additional active agent.

In one embodiment, provided herein is a method of treating, preventing, or controlling multiple myeloma, comprising administering to a patient Compound 1, Compound 2, or Compound 3, or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt, and a bispecific antibody that specifically binds the antigen. human B cell maturation (BCMA) and human CD3ε (CD3) as provided herein, in combination with one or more additional active agents and, optionally, in combination with radiation therapy, blood transfusion or surgery.

As used herein, the term combination includes the use of more than one therapy (eg, one or more prophylactic and/or therapeutic agents). However, use of the term in combination does not limit the order in which therapeutic agents (eg, prophylactic and/or therapeutic agents) are administered to a patient suffering from a disease or disorder. A first therapy (e.g., a prophylactic or therapeutic agent, such as a compound provided herein, such as Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as proposed herein) may be administered before (eg, 5, 15, 30, 45 min, 1, 2, 4, 6, 12, 24 , 48, 72, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks or 12 weeks), simultaneously with or after (for example, after 5, 15, 30, 45 minutes, 1, 2, 4, 6, 12, 24, 48, 72, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks) administration of additional therapy (eg, prophylactic or therapeutic agent) to the subject. Quadruple therapy is also discussed in this document, as is quintuple therapy. In one embodiment, the third therapeutic agent is dexamethasone.

Administration of Compound 1, Compound 2, or Compound 3 or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof and a bispecific antibody specifically binding to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein , and one or more additional active agents to the patient may be administered simultaneously or sequentially by the same or different routes of administration. The suitability of a particular route of administration used for a particular active agent depends on the active agent itself (eg, whether it can be administered orally without degrading before entering the bloodstream).

Route of administration of Compound 1, Compound 2 or Compound 3 or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue or a pharmaceutically acceptable salt thereof and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε. (CD3) proposed herein is independent of the route of administration of additional therapy. In od

- 50 043592 In this embodiment, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof is administered orally, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and CD3ε human (CD3) proposed herein is administered intravenously, but in one embodiment, through subcutaneous administration. In another embodiment, Compound 1, Compound 2, or Compound 3 is administered intravenously, and a bispecific antibody specifically binding to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein is administered intravenously, but in one embodiment, by subcutaneous administration. Thus, in these embodiments, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof is administered orally or intravenously, a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA). ) and human CD3ε (CD3) provided herein is administered intravenously, but in one embodiment, by subcutaneous administration, and additional therapy can be administered orally, parenterally, intraperitoneally, intravenously, intraarterially, transdermally, sublingually, intramuscularly, rectally, buccal, intranasal, liposomal, inhalation, vaginal, intraocular, local delivery via catheter or stent, subcutaneous, intra-adiposal, intra-articular, intrathecal or slow-release dosage form. In one embodiment, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof and the additional therapy are administered by the same route of oral or intravenous administration, and a bispecific antibody that specifically binds to a B-cell maturation antigen human (BCMA) and human CD3ε (CD3) as provided herein are administered intravenously, but in one embodiment, via subcutaneous administration. In another embodiment, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof is administered by one route of administration, for example, intravenous administration, while the additional agent (an anti-multiple myeloma agent) is administered by another route , for example, orally, and the bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein is administered by the intravenous route, but in one embodiment, via subcutaneous administration.

In one embodiment, the additional active agent is administered intravenously or subcutaneously and once or twice daily in an amount of from about 1 to about 1000 mg, from about 5 to about 500 mg, from about 10 to about 350 mg, or from about 50 to about 200 mg. The specific amount of additional active agent depends on the particular agent used, the type of multiple myeloma being treated or controlled, the severity and stage of the disease, and the amount of compound 1, compound 2 or compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue or a pharmaceutically acceptable salt and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein, as provided herein, and any optional additional active agents concurrently administered to the patient.

One or more additional active ingredients or agents can be used in conjunction with Compound 1, Compound 2, or Compound 3 and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein in the methods and the compositions proposed herein. Additional active agents may be high molecular weight compounds (eg, proteins), small molecules (eg, synthetic inorganic, organometallic, or organic molecules), or cell therapies (eg, CAR cells).

Examples of additional active agents that may be used in the methods and compositions described herein include one or more of the list including melphalan, vincristine, cyclophosphamide, etoposide, doxorubicin, bendamustine, a proteasome inhibitor (e.g., bortezomib, carfilzomib, ixazomib, oprosomib or marizomib), histone deacetylase inhibitor (for example, panobinostat, ACY241), BET inhibitor (for example, GSK525762A, OTX015, BMS-986158, TEN010, CPI-0610, INCB54329, BAY1238097, FT-1101, C90010, ABBV-075, BI 894999 Inhibitor BCL2 (eg, venetoclax or navitoclax), MCL-1 inhibitor (eg, AZD5991, AMG176, MIK665, S64315, or S63845), corticosteroid (eg, prednisone), dexamethasone; an antibody (eg, a CS1 antibody such as elotuzumab; a CD38 antibody such as daratumumab, isatuximab; or a BCMA antibody or antibody conjugate such as GSK2857916 or BI 836909), a checkpoint inhibitor (as described herein), or CAR cells (as described in this document).

In one embodiment, an additional active agent used in conjunction with Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to a B cell maturation antigen human (BCMA) and human CD3ε (CD3) as provided herein, in the methods and compositions described herein, is dexamethasone.

In some embodiments, dexamethasone is administered at a dosage of 4 mg on days 1 and 8 of a 21-day cycle. In some other embodiments, dexamethasone is administered at a dosage of 4 mg on days 1, 4, 8, and 11 of a 21-day cycle. In some embodiments, dexamethasone is administered at a dosage of 4 mg on days 1, 8, and 15 of a 28-day cycle. In some other embodiments, dexamethasone is administered at a dosage of 4 mg on days 1, 4, 8, 11, 15, and 18 of a 28-day cycle. In some embodiments, dexamethasone is administered at a dosage of 4 mg on days 1, 8, 15, and 22 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 4 mg on days 1, 10, 15, and 22 of Cycle 1. In some embodiments, dexamethasone is administered at a dosage of 4 mg on days 1, 3, 15, and 17 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 4 mg on days 1, 3, 14, and 17 of Cycle 1. In certain other embodiments, dexamethasone is administered at a dosage of 4 mg on days 1, 2, 4, 5, 8, 9, 11, and 12 21-day cycle (in one such embodiment, cycles 1-8). In some other embodiments, dexamethasone is administered at a dosage of 4 mg on days 1, 2, 8, and 9 of a 21-day cycle (in one embodiment, cycles > 9). In some other embodiments, dexamethasone is administered at a dosage of 4 mg on days 1, 2, 8, 9, 15, 16, 22, and 23 of a 28-day cycle.

In some other embodiments, dexamethasone is administered at a dosage of 8 mg on days 1 and 8 of a 21-day cycle. In some other embodiments, dexamethasone is administered at a dosage of 8 mg on days 1, 4, 8, and 11 of a 21-day cycle. In some embodiments, dexamethasone is administered at a dosage of 8 mg on days 1, 8, and 15 of a 28-day cycle. In some other embodiments, dexamethasone is administered at a dosage of 8 mg on days 1, 4, 8, 11, 15, and 18 of a 28-day cycle. In some embodiments, dexamethasone is administered at a dosage of 8 mg on days 1, 8, 15, and 22 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 8 mg on days 1, 10, 15, and 22 of Cycle 1. In some embodiments, dexamethasone is administered at a dosage of 8 mg on days 1, 3, 15, and 17 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 8 mg on days 1, 3, 14, and 17 of Cycle 1. In certain other embodiments, dexamethasone is administered at a dosage of 8 mg on days 1, 2, 4, 5, 8, 9, 11, and 12 21-day cycle (in one such embodiment, cycles 1-8). In some other embodiments, dexamethasone is administered at a dosage of 8 mg on days 1, 2, 8, and 9 of a 21-day cycle (in one embodiment, cycles > 9). In some other embodiments, dexamethasone is administered at a dosage of 8 mg on days 1, 2, 8, 9, 15, 16, 22, and 23 of a 28-day cycle.

In some embodiments, dexamethasone is administered at a dosage of 10 mg on days 1 and 8 of a 21-day cycle. In some other embodiments, dexamethasone is administered at a dosage of 10 mg on days 1, 4, 8, and 11 of a 21-day cycle. In some embodiments, dexamethasone is administered at a dosage of 10 mg on days 1, 8, and 15 of a 28-day cycle. In some other embodiments, dexamethasone is administered at a dosage of 10 mg on days 1, 4, 8, 11, 15, and 18 of a 28-day cycle. In some embodiments, dexamethasone is administered at a dosage of 10 mg on days 1, 8, 15, and 22 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 10 mg on days 1, 10, 15, and 22 of Cycle 1. In some embodiments, dexamethasone is administered at a dosage of 10 mg on days 1, 3, 15, and 17 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 10 mg on days 1, 3, 14, and 17 of Cycle 1. In some other embodiments, dexamethasone is administered at a dosage of 10 mg on days 1, 2, 4, 5, 8, 9, 11, and 12 21-day cycle (in one such embodiment, cycles 1-8). In some other embodiments, dexamethasone is administered at a dosage of 10 mg on days 1, 2, 8, and 9 of a 21-day cycle (in one embodiment, cycles > 9). In some other embodiments, dexamethasone is administered at a dosage of 10 mg on days 1, 2, 8, 9, 15, 16, 22, and 23 of a 28-day cycle.

In some embodiments, dexamethasone is administered at a dosage of 20 mg on days 1 and 8 of a 21-day cycle. In some other embodiments, dexamethasone is administered at a dosage of 20 mg on days 1, 4, 8, and 11 of a 21-day cycle. In some embodiments, dexamethasone is administered at a dosage of 20 mg on days 1, 8, and 15 of a 28-day cycle. In some other embodiments, dexamethasone is administered at a dosage of 20 mg on days 1, 4, 8, 11, 15, and 18 of a 28-day cycle. In some embodiments, dexamethasone is administered at a dosage of 20 mg on days 1, 8, 15, and 22 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 20 mg on days 1, 10, 15, and 22 of Cycle 1. In some embodiments, dexamethasone is administered at a dosage of 20 mg on days 1, 3, 15, and 17 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 20 mg on days 1, 3, 14, and 17 of Cycle 1. In some other embodiments, dexamethasone is administered at a dosage of 20 mg on days 1, 2, 4, 5, 8, 9, 11, and 12 21-day cycle (in one such embodiment, cycles 1-8). In some other embodiments, dexamethasone is administered at a dosage of 20 mg on days 1, 2, 8, and 9 of a 21-day cycle (in one embodiment, cycles > 9). In some other embodiments, dexamethasone is administered at a dosage of 20 mg on days 1, 2, 8, 9, 15, 16, 22, and 23 of a 28-day cycle.

- 52 043592

In some embodiments, dexamethasone is administered at a dosage of 40 mg on days 1 and 8 of a 21-day cycle. In some other embodiments, dexamethasone is administered at a dosage of 40 mg on days 1, 4, 8, and 11 of a 21-day cycle. In some embodiments, dexamethasone is administered at a dosage of 40 mg on days 1, 8, and 15 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 40 mg on days 1, 10, 15, and 22 of Cycle 1. In certain other embodiments, dexamethasone is administered at a dosage of 40 mg on days 1, 4, 8, 11, 15, and 18 of a 28-day period. cycle. In other such embodiments, dexamethasone is administered at a dosage of 40 mg on days 1, 8, 15, and 22 of a 28-day cycle. In other such embodiments, dexamethasone is administered at a dosage of 40 mg on days 1, 3, 15, and 17 of a 28-day cycle. In one such embodiment, dexamethasone is administered at a dosage of 40 mg on days 1, 3, 14, and 17 of Cycle 1. In some other embodiments, dexamethasone is administered at a dosage of 40 mg on days 1, 2, 4, 5, 8, 9, 11, and 12 21-day cycle (in one such embodiment, cycles 1-8). In some other embodiments, dexamethasone is administered at a dosage of 40 mg on days 1, 2, 8, and 9 of a 21-day cycle (in one embodiment, cycles > 9). In some other embodiments, dexamethasone is administered at a dosage of 40 mg on days 1, 2, 8, 9, 15, 16, 22, and 23 of a 28-day cycle.

In another embodiment, an additional active agent used in conjunction with Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein, in the methods and compositions described herein, is bortezomib. In another embodiment, an additional active agent used in conjunction with Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) as provided herein, in the methods and compositions described herein, is daratumumab. In some such embodiments, the methods further comprise administering dexamethasone. In some embodiments, the methods include administering Compound 1, Compound 2, or Compound 3 or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε ( CD3) provided herein, with a proteasome inhibitor as described herein, an anti-CD38 antibody as described herein, and a corticosteroid as described herein.

In certain embodiments, Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) , proposed herein, is administered concomitantly with checkpoint inhibitors. In one embodiment, one checkpoint inhibitor is used in combination with Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody that specifically binds to a human B cell maturation antigen. (BCMA) and human CD3ε (CD3) proposed herein in connection with the methods proposed herein. In another embodiment, two checkpoint inhibitors are used in combination with Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA). ) and human CD3ε (CD3) proposed herein, in relation to the methods presented herein in this document, represents. In another embodiment, three checkpoint inhibitors are used in combination with Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA). ) and human CD3ε (CD3) proposed herein, in relation to the methods presented herein in this document, represents.

As used herein, the term immune checkpoint inhibitor or checkpoint inhibitor refers to molecules that completely or partially reduce, inhibit, interfere with, or modulate one or more checkpoint proteins. Without being limited by theory, checkpoint proteins regulate T cell activation or function. Numerous checkpoint proteins are known, such as CTLA-4 and its ligands CD80 and CD86 and PD-1 with its ligands PD-L1 and PD-L2 (Pardoll, Nature Reviews Cancer, 2012, 12, 252-264). These proteins are responsible for costimulatory or inhibitory interactions of T cell responses. Immune checkpoint proteins are responsible for regulating and maintaining self-tolerance and the duration and amplitude of physiological immune responses. Immune checkpoint inhibitors include antibodies or are derived from antibodies.

In one embodiment, the checkpoint inhibitor is a CTLA-4 inhibitor. In one embodiment, the CTLA-4 inhibitor is an anti-CTLA-4 antibody. Examples of anti-CTLA-4 antibodies include, but are not limited to, those described in US Pat. Nos. 5,811,097; 5811097; 5855887; 6051227; 6207157; 6682736; 6984720 and 7605238, all of which are incorporated herein by reference in their entirety. In one embodiment, the anti-CTLA-4 antibody is tremelimumab (also known as ticilimumab or CP-675206). In another embodiment, the anti-CTLA-4 antibody is ipilimumab (also known as MDX-010 or MDX-101). Ipilimumab is a fully human monoclonal IgG antibody that binds to CTLA-4. Ipilimumab is marketed under the trade name Yervoy™.

In one embodiment, the checkpoint inhibitor is a PD1/PD-L1 inhibitor. Examples of PD-1/PD-L1 inhibitors include, but are not limited to, those described in US Pat. Nos. 7,488,802; 7943743; 8008449; 8168757; 8217149 and publications of patent application under the PCT No. WO 2003042402, WO 2008156712, WO 2010089411, WO 2010036959, WO 2011066342, WO 2011159877, WO 2011082400 and WO 20 11161699, all of which are incorporated herein in their entirety.

In one embodiment, the checkpoint inhibitor is a PD1 inhibitor. In one embodiment, the PD-1 inhibitor is an anti-PD-1 antibody. In one embodiment, the anti-PD-1 antibody is BGB-A317, nivolumab (also known as ONO-4538, BMS-936558, or MDX1106), or pembrolizumab (also known as MK-3475, SCH 900475, or lambrolizumab). In one embodiment, the anti-PD-1 antibody is nivolumab. Nivolumab is an IgG4 monoclonal antibody against human PD-1 and is marketed under the brand name Opdivo™. In another embodiment, the anti-PD-1 antibody is pembrolizumab. Pembrolizumab is a humanized IgG4 monoclonal antibody and is marketed under the trade name Keytruda™. In yet another embodiment, the anti-PD-1 antibody is CT-011, a humanized antibody. CT011, when administered by itself, did not demonstrate a response in the treatment of relapsed acute myeloid leukemia (AML). In yet another embodiment, the anti-PD-1 antibody is an AMP224 fusion protein. In another embodiment, the anti-PD-1 antibody is BGB-A317. BGB-A317 is a monoclonal antibody that is specifically engineered to bind to Fc gamma receptor I and has a unique PD-1 binding signature with high affinity and excellent target specificity.

In one embodiment, the checkpoint inhibitor is a PDL1 inhibitor. In one embodiment, the PD-L1 inhibitor is an anti-PD-L1 antibody. In one embodiment, the anti-PD-L1 antibody is MEDI4736 (durvalumab). In another embodiment, the anti-PD-L1 antibody is BMS-936559 (also known as MDX1105-01). In yet another embodiment, the PD-L1 inhibitor is atezolizumab (also known as MPDL3280A and Tecentriq®).

In one embodiment, the checkpoint inhibitor is a PDL2 inhibitor. In one embodiment, the PD-L2 inhibitor is an anti-PD-L2 antibody. In one embodiment, the anti-PD-L2 antibody is rHIgM12B7A.

In one embodiment, the checkpoint inhibitor is a lymphocyte activation gene 3 (LAG-3) inhibitor. In one embodiment, the LAG-3 inhibitor is IMP321, a soluble Ig fusion protein (Brignone et al, J. Immunol, 2007, 179, 4202-4211). In another embodiment, the LAG-3 inhibitor is BMS-986016.

In one embodiment, the checkpoint inhibitors are a B7 inhibitor. In one embodiment, the B7 inhibitor is a B7-H3 inhibitor or a B7-H4 inhibitor. In one embodiment, the B7-H3 inhibitor is MGA271, an anti-B7H3 antibody (Loo et al., Clin. Cancer Res., 2012, 3834).

In one embodiment, the checkpoint inhibitors are a TIM3 (T cell immunoglobulin domain and mucin domain 3) inhibitor (Fourcade et al., J. Exp. Med, 2010, 207, 2175-86; Sakuishi et al., J. Exp. Med, 2010, 207, 2175-86; Sakuishi et al., J. Exp. Med. Med, 2010, 207,2187-94).

In one embodiment, the checkpoint inhibitor is an OX40 agonist (CD134). In one embodiment, the checkpoint inhibitor is an anti-OX40 antibody. In one embodiment, the anti-OX40 antibody is anti-OX-40. In another embodiment, the anti-OX40 antibody is MEDI6469.

In one embodiment, the checkpoint inhibitor is a GITR agonist. In one embodiment, the checkpoint inhibitor is an anti-GITR antibody. In one embodiment, the anti-GITR antibody is TRX518.

In one embodiment, the checkpoint inhibitor is an agonist

- 54 043592

CD137. In one embodiment, the checkpoint inhibitor is an antibody to

CD137. In one embodiment, the anti-CD137 antibody is urelumab. In another embodiment, the anti-CD137 antibody is PF-05082566.

In one embodiment, the checkpoint inhibitor is a CD40 agonist. In one embodiment, the checkpoint inhibitor is an anti-CD40 antibody. In one embodiment, the anti-CD40 antibody is CF-870893.

In one embodiment, the checkpoint inhibitor is recombinant human interleukin-15 (rhIL-15).

In one embodiment, the checkpoint inhibitor is an IDO inhibitor. In one embodiment, the IDO inhibitor is INCB024360. In another embodiment, the IDO inhibitor is indoximod.

In some embodiments, the combination therapies provided herein include two or more checkpoint inhibitors described herein (including checkpoint inhibitors of the same or a different class). Moreover, the combination therapies described herein may be used in combination with one or more second active agents described herein as necessary to treat the diseases described herein and as required in the art.

In some embodiments, Compound 1, Compound 2, or Compound 3 and the bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein can be used in combination with one or more immune cells expressing one or more chimeric antigen receptors (CARs) on their surface (eg, a modified immune cell). Typically, CARs contain an extracellular domain of a first protein (eg, antigen binding protein), a transmembrane domain, and an intracellular signaling domain. In some embodiments, once the extracellular domain binds to a target protein, such as a tumor associated antigen (TAA) or tumor-specific antigen (TSA), a signal is generated through the intracellular signaling domain that activates the immune cell, for example, to target and kill the cell , expressing the target protein

Extracellular Domains: The extracellular domains of a CAR bind to the antigen of interest. In some embodiments, the extracellular domain of the CAR includes a receptor or portion of a receptor that binds to the antigen. In some embodiments, the extracellular domain comprises, or is, an antibody or an antigen-binding portion thereof. In specific embodiments, the extracellular domain comprises, or is a single chain Fv (scFv) domain. The single chain Fv domain may comprise, for example, VL linked to VH via a flexible linker, where _VL and VH are antibodies that bind said antigen.

In some embodiments, the antigen recognized by the extracellular domain of a polypeptide described herein is a tumor associated antigen (TAA) or a tumor specific antigen (TSA). In various specific embodiments, the tumor associated antigen or tumor-specific antigen is, without limitation, Her2, prostate stem cell antigen (PSCA), alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen-125 (CA- 125), CA19-9, calretinin, MUC-1, B-cell maturation antigen (BCMA), epithelial membrane protein (EMA), epithelial tumor antigen (ETA), tyrosinase, melanoma-24-associated antigen (MAGE), CD19, CD22, CD27, CD30, CD34, CD45, CD70, CD99, CD117, EGFRvIII (epidermal growth factor variant III), mesothelin, PAP (prostatic acid phosphatase), prostein, TARP (T-cell receptor alternative reading frame protein gamma), Trp -p8, STEAPI (six transmembrane epithelial prostate antigen 1), chromogranin, cytokeratin, desmin, glial fibrillary acidic protein (GFAP), acute cystic disease fluid protein (GCDFP-15), HMB-45 antigen, melan-A protein (antigen melanoma, T-lymphocyte recognition, MART-I), myo-DI, muscle-specific actin (MSA), neurofilament, neuron-specific enolase (NSE), placental alkaline phosphatase, synaptophysis, thyroglobulin, thyroid transcription factor-1, dimeric pyruvate kinase type M2 isoenzyme form (M2-PK tumor), abnormal ras protein, or abnormal p53 protein. In some other embodiments, the TAA or TSA recognized by the extracellular domain of the CAR is αΎβ3 integrin (CD61), galactin, or Ral-B.

In some embodiments, the TAA or TSA recognized by the extracellular domain of the CAR is a cancer-testis antigen (CT), e.g., BAGE, CAGE, CTAGE, FATE, GAGE, HCA661, HOM-TES-85, MAGEA, MAGEB, MAGEC, NA88 , NY-ES0-1, NY-SAR-35, OY-TES-1, SPANXBI, SPA17, SSX, SYCPI or TPTE.

In some other embodiments, the TAA or TSA recognized as the extracellular domain of the CAR is a carbohydrate or ganglioside, for example, fuc-GMI, GM2 (oncofetal antigen-immunogenic-1; OFA-I-1); GD2 (OFA-I-2), GM3, GD3 and the like.

- 55 043592

In some other embodiments, the TAA or TSA recognized as the extracellular domain of the CAR is alpha-actinin-4, Bage-1, BCR-ABL, Bcr-Ab1 fusion protein, betacatenin, CA 125, CA 15-3 (CA 27.29\BCAA ), CA 195, CA 242, CA-50, CAM43, Casp-8, cdc27, cdk4, cdkn2a, CEA, coa-l, dek-can fusion protein, EBNA, EF2, Epstein-Barr virus antigens, ETV6- fusion protein AML1, HLA-A2, HLA-All, hsp70-2, KIAA0205, Mart2, Mum-1, 2 and 3, neo-PAP, class I myosin, OS9, pml-RARa fusion protein, PTPRK, K-ras, N- ras, trisophosphate isomerase, Gage 3,4,5,6,7, GnTV, Herv-Kmel, Lage-1, NA-88, NY-Eso-1/Lage-2, SP17, SSX-2, TRP2-Int2, gp100 (Pmel17), tyrosinase, TRP-1, TRP-2, MAGE-1, MAGE-3, RAGE, GAGE-1, GAGE-2, p15(58), RAGE, S-1CP, Hom/Mel-40, PRAME , p53, HRa, HER-2/neu, E2A-PRL, H4-RET, IGH-IGK, MYL-RAR, human papillomavirus (HPV) E6 and E7 antigens, TSP-180, MAGE-4, MAGE-5, MAGE-6, p185erbB2, p180erbB-3, c-met, nm-23H1, PSA, TAG-72-4, CA 19-9, CA 72-4, CAM 17.1, NuMa, K-ras, 13-catenin, Mum -1, p16, TAGE, PSMA, CT7, telomerase, 439F, 5T4, 791Tgp72, 13HCG, BCA225, BTAA, CD68\KP1, C0-029, FGF-5, G250, Ga733 (EpCAM), HTgp175, M344, MA- 50, MG7-Ag, MOV18, NB\70K, NY-C0-1, RCAS1, SDCCAG16, TA-90, TAAL6, TAG72, TLP or TPS.

In various specific embodiments, the tumor-associated antigen or tumor-specific antigen are tumor antigens associated with AML, as described in S. Anguille et al, Leukemia (2012), 26, 2186-2196.

Other tumor-associated and tumor-specific antigens are known in the art.

Receptors, antibodies and scFvs that bind to TSA and TAA, suitable for the construction of chimeric antigen receptors, as well as nucleotide sequences that encode them, are known in the art.

In some specific embodiments, the antigen recognized by the extracellular domain of the chimeric antigen receptor is an antigen that is not typically considered a TSA or TAA, but that is nonetheless associated with tumor cells or tumor-induced damage. In some embodiments, for example, the antigen is, for example, a growth factor, cytokine, or interleukin, such as a growth factor, cytokine, or interleukin associated with angiogenesis or vasculogenesis. Such growth factors, cytokines or interleukins may include, for example, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), platelet-derived growth factor (PDGF), hepatocyte growth factor (HGF), insulin-like growth factor (IGF) or interleukin -8 (IL-8). Tumors can also create a hypoxic environment locally to the tumor. Thus, in other specific embodiments, the antigen is a hypoxia-associated factor, such as HIF-1a, HIF-1e, HIF-2a, HIF-2e, HIF3α, or HTF-3e. Tumors can also cause localized damage to normal tissue by causing the release of molecules known as pathogen-associated molecular pattern molecules (DAMPs; also known as alarmins). Thus, in some other specific embodiments, the antigen is a DAMP, e.g., heat shock proteins, high mobility chromatin-bound protein box 1 (HBGB 1), S100A8 (MRP8, calgranulin A), S100A9 (MRP14, calgranulin B), serum amyloid A (SAA) or may be deoxyribonucleic acid, adenosine triphosphate, uric acid or heparin sulfate.

Transmembrane domain

In some embodiments, the extracellular domain of the CAR is linked to the transmembrane domain of the polypeptide by a linker, spacer, or loop polypeptide sequence, such as a sequence from CD28 or a sequence from CTLA4. The transmembrane domain may be derived from or derived from the transmembrane domain of any transmembrane protein and may include all or part of such transmembrane domain. In specific embodiments, the transmembrane domain may be derived from or be derived from, for example, CD8, CD16, cytokine receptor and interleukin receptor or growth factor receptor or the like.

Intracellular signaling domains

In specific embodiments, a CAR intracellular domain is or comprises an intracellular domain or protein motif that is expressed on the surface of T cells and initiates activation and/or proliferation of said T cells. Such a domain or motif is capable of transmitting the primary antigen-binding signal, which is necessary for the activation of T lymphocytes in response to antigen binding to the extracellular part of the CAR. Typically this domain or motif contains or is an ITAM (immunoreceptor tyrosine activation motif). ITAM-containing polypeptides suitable for CAR include, for example, the CD3 zeta chain (CD3Z) or ITAM-containing portions thereof. In a specific embodiment, the intracellular domain is a CD3Z intracellular signaling domain. In other specific embodiments, the intracellular domain is a lymphocyte receptor chain, a TCR/CD3 complex protein, an Fe receptor subunit, or an IL-2 receptor subunit. In some embodiments, the CAR further comprises

- 56 043592 lives one or more co-stimulatory domains or motifs, for example, as part of the intracellular domain of the polypeptide. One or more costimulatory domains or motifs may be or may comprise one or more of a CD27 polypeptide costimulatory sequence, a CD28 polypeptide costimulatory sequence, an OX40 polypeptide costimulatory sequence (CD134), a 4-1BB polypeptide costimulatory sequence (CD137), or a costimulatory inducible T polypeptide sequence -cell (ICOS) or other co-stimulatory domain or motif, or any combination thereof.

CARs may also contain a T cell survival motif. A T cell survival motif can be any polypeptide sequence or motif that facilitates the survival of T lymphocytes following antigen stimulation. In some embodiments, the T cell survival motif is or is derived from CD3, CD28, IL-7 receptor (IL-7R) intracellular signaling domain, IL-12 receptor intracellular signaling domain, IL-15 receptor intracellular signaling domain, IL-15 receptor intracellular signaling domain -21 or the intracellular signaling domain of the transforming growth factor β receptor (TGFe).

Modified immune cells expressing CAR can be, for example, T lymphocytes (T cells, e.g. CD4+ T cells or CD8+ T cells), cytotoxic lymphocytes (CTL) or natural killer (NK) cells. The T lymphocytes used in the compositions and methods provided herein can be native T lymphocytes or MHC-restricted T lymphocytes. In some embodiments, the T lymphocytes are tumor infiltrating lymphocytes (TILs). In some embodiments, T lymphocytes were isolated from a tumor biopsy or were expanded from T lymphocytes isolated from a tumor biopsy. In some other embodiments, T cells have been isolated from or expanded from T lymphocytes isolated from peripheral blood, umbilical cord blood, or lymph. Immune cells to be used to generate modified immune cells expressing CAR can be isolated using conventional conventional methods, for example, blood collection followed by apheresis and, optionally, antibody-mediated cell isolation or sorting.

The modified immune cells are preferably autologous to the individual to whom the modified immune cells are to be administered. In some other embodiments, the modified immune cells are preferably allogeneic to the individual to whom the modified immune cells are to be administered. When allogeneic T lymphocytes or NK cells are used to produce modified T lymphocytes, T lymphocytes or NK cells are preferably selected, which reduces the likelihood of graft-versus-host disease (GVHD) occurring in the individual. For example, in some embodiments, virus-specific T lymphocytes are selected to produce modified T lymphocytes; such lymphocytes are expected to have a significantly reduced native ability to bind to, and thus be activated by, any recipient antigens. In some embodiments, recipient-mediated rejection of allogeneic T lymphocytes can be reduced by coadministration of one or more immunosuppressive agents to the host, for example, cyclosporine, tacrolimus, sirolimus, cyclophosphamide, or the like.

T lymphocytes, for example, unmodified T lymphocytes or T lymphocytes expressing CD3 and CD28, or containing a polypeptide containing a CD3Z signaling domain and a CD28 co-stimulatory domain, can be expanded using antibodies to CD3 and CD28, for example antibodies attached to beads ; see, for example, US Patent Nos. 5,948,893; 6534055; 6352694; 6692964; 6887466; and 6905681.

Modified immune cells, such as modified T lymphocytes, may optionally contain a suicide gene or safety switch that, if desired, allows substantially all of the modified immune cells to be killed. For example, the modified T lymphocytes, in some embodiments, may contain the HSV thymidine kinase (HSV-TK) gene, which causes the modified T lymphocytes to die when exposed to ganciclovir. In another embodiment, the modified T lymphocytes contain an inducible caspase, for example, inducible caspase 9 (icaspase9), for example, a fusion protein between caspase 9 and human FK506-binding protein, which allows dimerization using a specific pharmaceutical small molecule. See Straathof et al., Blood 1 05(11):4247-4254 (2005).

J. Pharmaceutical compositions

The pharmaceutical compositions provided herein contain a therapeutically effective amount of one or more compounds provided herein, and optionally a pharmaceutically acceptable carrier, diluent or excipient.

In a further embodiment, provided herein is a pharmaceutical composition comprising a compound provided herein and a bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein, a pharmaceutically acceptable excipient. , not necessary,

- 57 043592 wherein the bispecific antibody comprises a first binding portion that specifically binds to human B-cell maturation antigen (BCMA) and a second binding portion that specifically binds to human CD3ε (CD3), wherein said first binding portion comprises a VH region containing a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22, and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28.

In one embodiment, the composition is for combination use in the treatment of multiple myeloma.

In a further embodiment, provided herein is a pharmaceutical composition comprising Compound 1, Compound 2, or Compound 3, or an enantiomer, mixture of enantiomers, tautomer, isotopologue, or pharmaceutically acceptable salt thereof, and a bispecific antibody comprising a first binding moiety that specifically binds to a B cell maturation antigen human (BCMA), and a second binding moiety specifically binding to human CD3ε (CD3) as provided herein, optionally wherein the bispecific antibody is characterized in that said first binding moiety comprises a VH region comprising a CDR1H region of SEQ ID NO: 21 , a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17 and a VL region comprising a CDR3L region of SEQ ID NO: 20 and a combination of CDR1L and CDR2L regions selected from the group:

i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28, and a pharmaceutically acceptable excipient. In one embodiment, the composition is for combination use in the treatment of multiple myeloma.

These compounds may be formulated into suitable dosage forms such as solutions, suspensions, tablets, dispersible tablets, pills, capsules, powders, sustained release preparations or elixirs, for oral administration, or in sterile solutions or suspensions for ophthalmic or parenteral administration, as well as transdermal patch and dry powder inhalers. Typically, the compounds described above are formulated into pharmaceutical compositions using methods and techniques well known in the art (see, for example, Ansel Introduction to Pharmaceutical Dosage Forms, 7th ed. 1999).

In these compositions, effective concentrations of one or more compounds or pharmaceutically acceptable salts thereof are admixed with a suitable pharmaceutical carrier or excipient. In specific embodiments, the concentrations of the compounds in the compositions are effective to deliver an amount that, when administered, treats, prevents, or alleviates one or more symptoms and/or progression of multiple myeloma.

Typically, the compositions are formulated for a single dose administration. To prepare the composition, a bulk portion of the compound is dissolved, suspended, dispersed, or otherwise mixed in the selected excipient at such an effective concentration that the pathological condition is alleviated or improved. Pharmaceutical carriers or excipients suitable for administering the compounds provided herein include any such carriers known to those skilled in the art suitable for the particular route of administration.

In addition, the compounds may be formulated as the sole pharmaceutically active ingredient in a composition or may be combined with other active ingredients. Liposomal suspensions, including tissue-targeted liposomes such as tumor-targeted liposomes, may also be useful as pharmaceutically acceptable carriers. They can be prepared in accordance with methods known to those skilled in the art. For example, liposomal dosage forms can be prepared as known in the art. Briefly, liposomes such as multilayer vesicles (MLVs) can be formed by drying egg phosphatidylcholine and brain phosphatidylserine (7:3 molar ratio) on the inside of a flask. A solution of the compound provided herein in phosphate buffered saline (PBS) lacking divalent cations is added and the flask is stirred until the lipid film is dispersed. The resulting vesicles are washed to remove unencapsulated compound, pelleted by centrifugation and then resuspended in PBS.

The active compound is included in the pharmaceutically acceptable excipient in an amount sufficient to provide a therapeutically beneficial effect without causing undesirable side effects to the patient being treated. The therapeutically effective concentration can be determined empirically by testing compounds in in vitro and in vivo systems described in this document.

- 58 043592 document, and then extrapolated from this for dosage for humans.

The concentration of the active compound in the pharmaceutical composition will depend on the rates of absorption, tissue distribution, inactivation, metabolism and excretion of the active compound, the physicochemical characteristics of the compound, the dosing schedule and amount of the substance administered, and other factors known to those skilled in the art. For example, the amount that is delivered is sufficient to improve one or more symptoms of cancer, including solid tumors and hematologic tumors.

Solutions or suspensions for parenteral, intradermal, subcutaneous or topical use may include any of the following: a sterile diluent such as water for injection, saline, fixed oil, polyethylene glycol, glycerin, propylene glycol, dimethyl acetamide or other synthetic solvent; antimicrobial agents such as benzyl alcohol and methylparaben; antioxidants such as ascorbic acid and sodium bisulfite; chelating agents such as ethylenediaminetetraacetic acid (EDTA); buffers such as acetates, citrates and phosphates; and tonicity adjusters such as sodium chloride or dextrose. Parenteral preparations may be contained in ampoules, pen syringes, disposable syringes, or single-use or refillable vials of glass, plastic, or other suitable material.

In cases where compounds exhibit insufficient solubility, methods for solubilizing compounds can be used. Such methods are known to those skilled in the art and include, but are not limited to: the use of co-solvents such as dimethyl sulfoxide (DMSO), the use of surfactants such as TWEEN®, or dissolution in an aqueous solution of sodium bicarbonate.

When the compound(s) are mixed or added, the resulting mixture may be a solution, suspension, emulsion, or the like. The dosage form of the resulting mixture depends on a number of factors, including the intended route of administration and the solubility of the compound in the selected carrier or excipient. An effective concentration is sufficient to reduce the symptoms of a disease, disorder or pathology, and can be determined empirically.

Pharmaceutical compositions are intended for administration to humans and animals in unit dose dosage forms such as tablets, capsules, pills, powders, granules, sterile parenteral solutions or suspensions, and oral solutions or suspensions, as well as oil-water emulsions containing suitable the amount of compounds or pharmaceutically acceptable salts thereof. Pharmaceutically therapeutically active compounds and their salts are formulated and administered in unit dosage forms or multiple dose dosage forms. Unit dosage forms as used herein refer to physically discrete units suitable for use in humans and animals and are individually packaged as is known in the art. Each unit dose contains a predetermined amount of a therapeutically active compound sufficient to produce the desired therapeutic effect, in combination with the necessary pharmaceutical carrier, excipient or diluent. Examples of unit dosage forms include ampoules and syringes, and individually packaged tablets or capsules. Unit dosage forms may be administered in portions or multiples thereof. A multiple-dose dosage form is a plurality of identical single-dose dosage forms packaged in a single container to be administered in separate single-dose dosage forms. Examples of multi-dose dosage forms include vials, tablet or capsule bottles, or pint or gallon bottles. Therefore, multiple dose dosage forms are multiples of unit doses that are not divided in the package.

Dosage forms or compositions can be prepared containing the active ingredient in the range of 0.005 to 100%, the remainder being a non-toxic carrier. For oral administration, a pharmaceutically acceptable non-toxic composition is prepared by adding any of the commonly used excipients, such as, for example, pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, talc, cellulose derivatives, crosscarmellose sodium, glucose, sucrose, magnesium carbonate or sodium saccharin . Such compositions include solutions, suspensions, tablets, capsules, powders and sustained release dosage forms such as, but not limited to, implants and microencapsulated delivery systems, and biodegradable biocompatible polymers such as collagen, ethylene vinyl acetate, polyanhydrides, polyglycolic acid, polyorthoesters, polylactic acid and others. Methods for preparing these compositions are known to those skilled in the art.

The active compounds or pharmaceutically acceptable salts can be formulated with carriers that protect the compound from rapid elimination from the body, such as time-release dosage forms or coated formulations.

The compositions may contain other active compounds to provide the desired combinations of properties. The compounds provided herein, or their pharmaceutically acceptable salts as described herein, may also advantageously be administered for therapeutic or prophylactic purposes together with another pharmacological agent that is known in the art to be useful in the treatment of one or more of the diseases or medical conditions mentioned above herein, such as diseases associated with oxidative stress. It should be understood that such combination therapy represents an additional aspect of the compositions and methods of treatment presented herein.

K. Evaluation of the activity and properties of the combination

Standard physiological, pharmacological, and biochemical procedures are available to screen compounds to identify those that have desired properties, including activity against multiple myeloma proliferation and an adequate safety profile. Such assays include, for example, biochemical assays such as binding assays, radioactive inclusion assays, and various cell-based assays.

It is understood that the foregoing detailed description and accompanying examples are merely illustrative and should not be construed as limiting the scope of the invention. Various changes and modifications to the described embodiments will be apparent to those skilled in the art. Such changes and modifications, including, without limitation, those relating to the chemical structures, substituents, derivatives, intermediates, syntheses, formulations and/or methods of use provided herein, may be made without departing from the spirit and scope of the document. US patents and publications referenced herein are incorporated herein by reference.

5. Examples

Some embodiments of the present invention are illustrated by the following non-limiting examples.

Abbreviations:

AIBN: azobiisobutyronitrile

Vos tert-buto xi carbon silt

Vos ₂ O di-tre/i-butyl dicarbonate tBuOK 7/?et-potassium butoxide

DIPEA diisopropylethylamine

DMF N, N'-Dimethylformamide

EtOAc ethyl acetate

MeOH methanol

MM multiple myeloma

NBS: N-bromosuccinimide

NMR nuclear magnetic resonance i-PrOAc: isopropyl acetate

TV SCI tert-butyldimethylsilyl chloride

ΤΓΦ tetrahydrofuran

TCX thin layer chromatography

TMSC1 trimethylsilyl chloride

Example 1. Synthesis of 4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1-oxoisoindolin-4-yl)oxy)methyl)benzyl)piperazin-1-yl)- 3-fluorobenzonitrile (Compound 1).

O

2-Amino-5-methoxy-5-oxopentanoic acid.

To a suspension of 2-aminopentanedic acid (250 g, 1.70 mol) in dry methanol (2.5 L) under nitrogen was added trimethylsilyl chloride (277 g, 2.55 mol) over 30 minutes. The resulting clear solution was stirred at room temperature (20°C) for 30 minutes. 1H NMR showed that the starting material was completely consumed. The reaction mixture was used in the next step without further processing.

1H NMR: 400 MHz CD3OD δ: 4.17-4.15 (m, 1H), 3.71 (s, 3H), 2.70-2.60 (m, 2H), 2.33-2.25 (m, 2H).

2-((tert-Butoxycarbonyl)amino)-5-methoxy-5-oxopentanoic acid.

Triethylamine (275 g, 2.72 mol) and di-tert-butyl dicarbonate (447.35 g, 2.05 mol) were added to the resulting solution. The reaction mixture was stirred at 25°C for 2 hours. The solution was evaporated to dryness, then water (2.5 L) was added to dissolve the residue. The resulting aqueous phase was washed with ethyl acetate (200 ml), then acidified to pH=3 with HCl (1H) and extracted with ethyl acetate (1 L x 3). The organic layers were washed with brine (800 ml), dried over sodium sulfate, filtered and evaporated to give 2-(tert-butoxycarbonylamino)-5-methoxy-5-oxopentanoic acid (250 g, 56% yield, two steps) as white solid matter.

1H NMR: 400 MHz CD3OD δ: 4.18-4.11 (m, 1H), 3.69 (s, 3H), 2.48-2.43 (m, 2H), 2.21-2.15 (m, 1H), 1.95- 60 043592

1.91 (m, 1H), 1.46 (s, 9H).

Methyl 5-amino-4-(tert-butoxycarbonylamino)-5-oxopentanoate.

To a solution of 2-(tert-butoxycarbonylamino)-5-methoxy-5-oxopentanoic acid (200 g, 765 mmol) in 1,4-dioxane (1.5 L) was added di-tert-butyl dicarbonate (267 g, 1. 22 mmol) and pyridine (121 g, 1.53 mol). After the reaction mixture was stirred at 25°C for 30 minutes, ammonium carbonate (182 g, 2.30 mol) was added to the mixture and stirred for an additional 16 hours at 25°C. The organic solvent was removed on a rotary evaporator, the residue was acidified with HCl (6 M) to pH=3, and then extracted with ethyl acetate (800 ml x 3). The combined organic phase was washed with brine (800 ml), dried over sodium sulfate and filtered. VOCs were removed under reduced pressure to give methyl 5-amino-4-(tert-butoxycarbonylamino)-5-oxopentanoate (180 g, 90% yield) as a white solid.

^1H NMR: 400 MHz CDCL δ: 6.51 (s, 1H), 5.94 (s, 1H), 5.43 (s, 1H), 4.21 (s, 1H), 3.63 (s , 3H), 2.59-2.40 (m, 2H), 2.15-2.11 (m, 1H), 1.94-1.90 (s, 1H), 1.42 (s, 9H ).

Methyl 4,5-diamino-5-oxopentanoate hydrochloride.

A mixture of methyl 5-amino-4-(tert-butoxycarbonylamino)-5-oxopentanoate (180 g, 692 mmol) and HCl/ethyl acetate (300 ml, 4 M) was stirred at 25°C for 12 hours. The precipitated solid was collected by vacuum filtration and washed with ethyl acetate (500 ml) to obtain methyl 4,5-diamino-5-oxopentanoate hydrochloride (130 g, 95% yield) as a white solid.

1H NMR: 400 MHz CD3OD δ: 4.00-3.96 (m, 1H), 3.70 (s, 3H), 2.59-2.52 (m, 2H), 2.22-2.13 (m, 2H).

Methyl 3-hydroxy-2-methylbenzoate.

Four loads (200 g each) were carried out in parallel. To a solution of 3-hydroxy-2-methylbenzoic acid (200 g, 1.31 mol) in methanol (4.0 L) was added concentrated sulfuric acid (47.7 g, 486 mmol). The reaction mixture was stirred at 60°C for 17 hours. The reaction mixture was evaporated to 800 ml. The resulting mixture was cooled to 20°C and slowly poured into water (400 ml) over 30 minutes. Water (1200 ml) was added at 20°C for 3 hours and the resulting mixture was stirred at 20°C for 1 hour. The precipitated solid was collected by vacuum filtration (four batches combined) and washed three times with water/methanol (1000 ml, 9: 1) to pH > 3. The solid was dried in vacuum at 45°C to obtain methyl 3-hydroxy-2-methyl benzoate (700 g, 80.4% yield) as a gray solid.

1H NMR: 400 MHz DMSO-d ₆ δ: 9.70 (s, 1H), 7.18 (t, J=6.8 Hz, 1H), 7.09 (t, J=7.6 Hz, 1H ), 7.00 (t, J=6.8 Hz, 1H), 3.81 (s, 3H), 2.29 (s, 3H).

Methyl 3-[tert-butyl(dimethyl)silyl]oxy-2-methylbenzoate.

Two loads (240 g each) were carried out in parallel. To a solution of methyl 3-hydroxy-2-methylbenzoate (240 g, 1.44 mol) in N,N-dimethylformamide (1.40 L) was added imidazole (246 g, 3.61 mol) and tert-butyldimethylsilyl chloride (238 g, 1. 58 mol) at 5°C. After addition, the mixture was heated to 20°C and stirred for 6 hours. Isopropyl acetate (1700 ml) was added and then water (2000 ml) was added slowly while the temperature was maintained below 30°C. The resulting mixture was stirred and the organic phase was separated. The combined organic phase (combined two loads) was washed with water (1700 ml x 3) and evaporated to ~1500 ml (KF < 0.05%). The product was stored as a solution in isopropyl acetate, which was used for the next step without further purification.

Methyl 2-(bromomethyl)-3-[tert-butyl(dimethyl)silyl]oxybenzoate.

Two loads (~375 g each) were carried out in parallel. Nbromosuccinimide (274 g, 1.54 mol) and azobisisobutyronitrile (4.40 g, 26. 8 mmol). The reaction mixture was heated to 70°C for at least 1 hour and stirred at 70°C for 4 hours. The reaction mixture was cooled to 20°C and kept at 20°C for at least 1 hour. Two loads of solids (succinimide) was removed by filtration and washed with isopropyl acetate (700 ml). The filtrate was washed with a saturated solution of sodium sulfite (700 g) in water (6000 ml), then with water (1500 ml). The organic layer was distilled in vacuo at 45°C to dryness to obtain methyl 2-(bromomethyl)-3-[tert-butyl(dimethyl)silyl]oxybenzoate. (920 g, 95.5% yield) as a dark orange oil.

1H NMR: 400 MHz DMSO-d ₆ δ: 7.45 (d, J=6.8 Hz, 1H), 7.36 (t, J=8.0 Hz, 1H), 7.13 (t, J =7.2 Hz, 1H), 4.95 (s, 2H), 1.02 (s, 9H), 0.29 (s, 6H).

Methyl 5-amino-4-[4-[tert-butyl(dimethyl)silyl]oxy-1-oxoisoindolin-2-yl]-5-oxopentanoate.

To a stirred solution of methyl 4,5-diamino-5-oxopentanoate hydrochloride (74.5 g, 379 mmol) in acetonitrile (2.50 L) was added methyl 2-(bromomethyl)-3-[tert-butyl(dimethyl)silyl] hydroxybenzoate (125 g, 348 mmol). Diisopropylethylamine (89.9 g, 696 mmol) was added to the suspension via a dropping funnel over 10 min and then the mixture was stirred at 60°C for 16 h. The reaction mixture was diluted with ethyl acetate (1.0 L), washed successively with HCl (1H, 1.0 l), sodium bicarbonate (sat. 1.0 l) and saline solution (1.0 l). The organic layer was evaporated to give crude methyl 5-amino-4-[4-[tert-butyl(dimethyl)silyl]oxy-1-oxoisoindolin-2-yl]-5-oxopen-tanoate (108 g, crude product) as a pale yellow solid. LC-MS: m/z 407.3

[M+1]+.

Methyl 5-amino-4-(4-hydroxy-1-oxoisoindolin-2-yl)-5-oxopentanoate.

To a stirred cold solution of methyl 5-amino-4-[4-[tert-butyl(dimethyl)silyl]oxy-1oxoisoindolin-2-yl]-5-oxopentanoate (108 g, 266 mmol) in N,N-dimethylformαmide (350 ml) potassium carbonate (14.7 g, 106 mmol) in water (40 ml) was added in portions over 5 min. The resulting reaction mixture was stirred at 15°C for 15 hours. The reaction mixture was cooled in an ice bath and HCl (12 M, 15 ml) was slowly added at 0-5°C. Acetonitrile (200 ml) was added to the mixture and a solid precipitate formed. The suspension was stirred at room temperature for 10 minutes and filtered. The filter cake was washed with ethyl acetate (200 ml x 5) to obtain the product (55 g). The filtrate was evaporated under high vacuum to obtain crude product (100 g) which was dissolved in dichloromethane (1.0 L) and left to stand at 15°C for 16 hours. A white solid formed which was filtered to obtain 5 g of product. The solids were combined to give methyl 5-amino-4-(4-hydroxy-1-oxoisoindolin-2-yl)-5-oxopentanoate (60 g, 77% yield) as a white solid.

1H NMR: 400 MHz DMSO-d ₆ δ: 7.58 (s, 1H), 7.31 (t, J=8.0 Hz, 1H), 7.19-7.14 (m, 2H), 7 .01 (d, J=7.6 Hz, 1H), 4.75-4.71 (m, 1H), 4.50 (d, J=17.6 Hz, 1H), 4.32 (d, J=17.6 Hz, 1H), 3.51 (s, 3H), 2.29-2.18 (m, 3H), 2.091.99 (m, 1H).

Methyl 5-amino-4-[4-[[4-(bromomethyl)phenyl]methoxy]-1-oxoisoindolin-2-yl]-5-oxopentanoate.

Two reactions (25 g, 85.5 mmol) were carried out in parallel. A mixture of 1,4-bis(bromomethyl)benzene (67.7 g, 257 mmol), potassium carbonate (11.8 g, 85.5 mmol) and methyl 5-amino-4-(4-hydroxy-1-oxoisoindoline- 2yl)-5-oxopentanoate (25 g, 85.5 mmol) in acetonitrile (1 L) was stirred at 60°C for 16 hours. The two batches were combined and the mixture was cooled to 15°C and filtered. The filtrate was concentrated and purified by silica gel column chromatography (eluting from 50% petroleum ether in ethyl acetate to 100% ethyl acetate) to give methyl 5-amino-4-[4-[[4-(bromomethyl)phenyl]methoxy]-1-oxoisoindoline -2-yl]5-oxopentanoate (52 g, 63% yield) as a white solid.

1H NMR: 400 MHz DMSO-d6 δ: 7.59 (s, 1H), 7.50-7.44 (m, 5H), 7.32-7.28 (m, 2H), 7.19 (s , 1H), 5.26 (s, 2H), 4.79-4.71 (m, 3H), 4.55 (d, J=17.6 Hz, 1H), 4.43 (d, J= 17.6 Hz, 1H), 3.52 (s, 3H), 2.30-2.19 (m, 3H), 2.102.08 (m, 1H).

3-[4-[[4-(bromomethyl)phenyl]methoxy]-1-oxoisoindolin-2-yl]piperidin-2,6-dione.

Two reactions (28.5 g, 60.0 mmol) were carried out in parallel. Methyl 5-amino-4-[4-[[4(bromomethyl)phenyl]methoxy]-1-oxoisoindolin-2-yl]-5-oxopentanoate (28.5 g, 60.0 mmol) was dissolved in tetrahydrofuran (720 ml ) and the solution was cooled with a dry ice/acetone bath to -70°C. While stirring, potassium tert-butoxide (7.4 g, 66.0 mmol) was added to the clear solution in one portion. The reaction mixture turned pale yellow and stirring was continued for another 2 hours at -70°C. Cooled HCl solution (1 N, 260 ml) was quickly added to the reaction mixture, maintaining the temperature at -70°C. The mixture immediately turned milky white and the dry ice/acetone bath was removed. The mixture was evaporated to remove most of the tetrahydrofuran. After evaporation of the reaction mixture, a white solid precipitated. The white suspension was diluted with water (500 ml) and then filtered. The filter cake was washed with water (500 ml) and dried in a vacuum oven at 40°C for 12 hours, then washed with ethyl acetate (500 ml). The batches were combined to give 3-[4-[[4(bromomethyl)phenyl]methoxy]-1-oxoisoindolin-2-yl]piperidin-2,6-dione (49.85 g, 93%) as a light yellow solid substances.

1H NMR: 400 MHz DMSO-d ₆ δ: 10.95 (s, 1H), 7.51-7.41 (m, 5H), 7.35-7.28 (m, 2H), 5.23 (s, 2H), 5.125.07 (m, 1H), 4.70 (s, 2H), 4.41 (d, J=17.6 Hz, 1H), 4.25 (d, J=17, 6 Hz, 1H), 2.90-2.84 (m, 1H), 2.58-2.53 (m, 1H), 2.44-2.41 (m, 1H), 1.98-1 .95 (m, 1H).

4-(4-(4-(((2-(2,6-Dioxopiperidin-3-yl)-1-oxoisoindolin-4-yl)oxy)methyl)benzyl)piperazin-1yl)-3-fluorobenzonitrile.

3-(4-((4-(Bromomethyl)benzyl)oxy)-1-oxoisoindolin-2-yl)piperidin-2,6-dione (5.0 g, 11.28 mmol) was added to the flask with 3-fluoro -4-(piperazin-1-yl)benzonitrile (2.315 g, 11.28 mmol), diisopropylethylamine (5.91 ml, 33.8 mmol) and acetonitrile (100 ml). The reaction mixture was stirred at 40°C for 18 hours. Volatile organic compounds were removed under reduced pressure and purification by standard methods gave 4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1 -oxoisoindolin-4-yl)oxy)methyl)benzyl)piperazin-1-yl)-3-fluorobenzonitrile.

1H NMR (400 MHz, DMSO-d ₆ ) δ 10.97 (s, 1H), 7.68 (dd, J=1.96, 13.45 Hz, 1H), 7.56 (dd, J=1 .77, 8.38 Hz, 1H), 7.43-7.52 (m, 3H), 7.30-7.38 (m, 4H), 7.11 (t, J=8.80 Hz, 1H), 5.24 (s, 2H), 5.11 (dd, J=5.14, 13.33 Hz, 1H), 4.37-4.46 (m, 1H), 4.22-4 .30 (m, 1H), 3.54 (s, 2H), 3.12-3.23 (m, 4H), 2.84-2.98 (m, 1H), 2.52-2.62 (m, 5H), 2.36-2.48 (m, 1H), 1.92-2.04 (m, 1H). MS (ESI) m/z 568.2 [M+1] ⁺ . Anal. calculation for C32H30FN5O4: C, 67.71; N, 5.33; N, 12.34. Observed: C, 67.50; N, 5.44; N 12.34.

- 62 043592

Example 2. Synthesis of (S)-4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1-oxoisoindolin-4-yl)oxy)methyl)benzyl)piperazine-1 -yl)-3-fluorobenzonitrile (Compound 2) o

tert-Butyl (4S)-5-amino-4-(benzyloxycarbonylamino)-5-oxo-pentanoate.

Di-tert-butyl dicarbonate (155 g, 711 mmol), pyridine (70.3 g, 889 mmol) and ammonium bicarbonate (105 g, 1.33 mol). The reaction mixture was stirred at 18°C for 16 hours and then evaporated. The residue was dissolved in ethyl acetate (5.0 L) and water (5.0 L), the organic layer was separated and washed with HCl (3.0 mL, 1 N), saturated sodium hydrogen carbonate solution (3.0 L), brine (3 .0 L), dried over anhydrous sodium sulfate, filtered and evaporated to give crude tert-butyl (48)-5-amino-4-(benzyloxycarbonylamino)-5-oxopentanoate (450 g, crude) as a white solid, which used in the next step without further purification.

1H NMR 400 MHz DMSO-d ₆ δ: 7.35-7.30 (m, 5H), 7.02 (s, 1H), 5.01 (d, J=3.2 Hz, 1H), 3, 93-3.90 (m, 1H), 2.20 (t, J=8.0 Hz, 2H), 1.88-1.84 (m, 1H), 1.72-1.69 (m, 1H), 1.35 (s, 9H).

tert-Butyl (4S)-4,5-diamino-5-oxopentanoate.

To a solution of tert-butyl (48)-5-amino-4-(benzyloxycarbonylamino)-5-oxopentanoate (112 g, 333 mmol) in methanol (1.0 L) was added 10% palladium on carbon (15 g) under a nitrogen atmosphere . The suspension was degassed under vacuum and purged with hydrogen several times. The mixture was stirred under an atmosphere of hydrogen (40 psi, 2.75 bar) at 30°C for 16 hours. The reaction mixture was filtered and the filtrate was concentrated to give crude tert-butyl (4S)-4,5-diamino-5 -oxopentanoate in the form of a colorless oil.

1H NMR 400 MHz DMSO-a ₆ δ: 7.30 (s, 1H), 6.95 (s, 1H), 3.10-3.07 (m, 1H), 2.27-2.23 (m , 2H), 1.69-1.78 (m, 1H), 1.59-1.55 (m, 1H), 1.38 (s, 9H).

Methyl 3-hydroxy-2-methylbenzoate.

Four loads (200 g each) were carried out in parallel. To a solution of 3-hydroxy-2-methylbenzoic acid (200 g, 1.31 mol) in methanol (4.0 L) was added concentrated sulfuric acid (47.7 g, 486 mmol). The reaction mixture was stirred at 60°C for 17 hours. The reaction mixture was evaporated to 800 ml. The resulting mixture was cooled to 20°C and slowly poured into water (400 ml) over 30 min. Water (1200 ml) was added at 20°C for 3 hours and the resulting mixture was stirred at 20°C for 1 hour. The precipitated solid was collected by vacuum filtration (four batches combined) and washed three times with water/methanol (1000 ml, 9: 1) to pH > 3. The solid was dried in vacuum at 45 °C to obtain methyl 3-hydroxy-2-methyl benzoate (700 g, 80.4% yield) as a gray solid.

1H NMR: 400 MHz DMSO δ: 9.70 (s, 1H), 7.18 (t, J=6.8 Hz, 1H), 7.09 (t, J=7.6 Hz, 1H), 7 .00 (t, J=6.8 Hz, 1H), 3.81 (s, 3H), 2.29 (s, 3H).

Methyl 3-[tert-butyl(dimethyl)silyl]oxy-2-methylbenzoate.

Two loads (240 g each) were carried out in parallel. To a solution of methyl 3-hydroxy-2-methylbenzoate (240 g, 1.44 mol) in N,N-dimethylformamide (1.40 L) was added imidazole (246 g, 3.61 mol) and tert-butyldimethylsilyl chloride (238 g, 1. 58 mol) at 5°C. After addition, the mixture was heated to 20°C and stirred for 6 hours. Isopropyl acetate (1700 ml) was added and then water (2000 ml) was added slowly while the temperature was maintained below 30°C. The resulting mixture was stirred, followed by separation of the organic phase. The combined organic phases (combined two loads) were washed with water (1700 ml x 3) and evaporated to -1500 ml (KF < 0.05%). The product was stored as a solution in isopropyl acetate, which was used for the next step without further purification.

Methyl 2-(bromomethyl)-3-[tert-butyl(dimethyl)silyl]oxy-benzoate. Two loads (-375 g each) were carried out in parallel. N-bromosuccinimide (274 g, 1.54 mol) and azobisisobutyronitrile (4.40 g, 26.8 mmol). The reaction mixture was heated to 70°C for at least 1 hour and stirred at 70°C for 4 hours. The reaction mixture was cooled to 20°C and kept at 20°C for at least 1 hour. Two loads of solids (succinimide) was removed by filtration and washed with isopropyl acetate (700 ml). The filtrate was washed with a saturated solution of sodium sulfite (700 g) in water (6000 ml), then with water (1500 ml). The organic layer was distilled in vacuo at 45°C to dryness to obtain methyl 2-(bromomethyl)-3-[tert-butyl(dimethyl)silyl]oxybenzoate. (920 g, 95.5% yield) as a dark orange oil.

1H NMR: 400 MHz DMSO-d ₆ δ: 7.45 (d, J=6.8 Hz, 1H), 7.36 (t, J=8.0 Hz, 1H), 7.13 (t, J =7.2 Hz, 1H),

- 63 043592

4.95 (s, 2H), 1.02 (s, 9H), 0.29 (s, 6H).

tert-Butyl (4S)-5-amino-4-[4-[tert-butyl(dimethyl)silyl]oxy-1-oxoisoindolin-2-yl]-5-oxopentanoate.

To a solution of tert-butyl (4S)-4,5-diamino-5-oxopentanoate (130 g, 643 mmol) in acetonitrile (4.0 L) was added methyl 2-(bromomethyl)-3-[tert-butyl(dimethyl) silyl]oxybenzoate (210 g, 584 mmol) and diisopropylethylamine (113 g, 877 mmol). The reaction mixture was stirred at 50°C for 16 hours. The reaction mixture was evaporated to remove most of the acetonitrile, the residue was dissolved in methyl tert-butyl ether (2.0 L) and water (1.5 L), the organic layer was washed with saturated potassium dihydrogen phosphate solution (1.0 L x 2), brine (1.0 L), dried over anhydrous sodium sulfate, filtered and evaporated to give crude tert-butyl (4S)-5-amino-4-[4-[tert-butyl(dimethyl )silyl]oxy-1-oxoisoindolin-2-yl]-5-oxopentanoate (524 g), which was used in the next step without further purification.

tert-Butyl (4S)-5-amino-4-(4-hydroxy-1-oxo-isoindolin-2-yl)-5-oxopentanoate.

To a solution of tert-butyl (4S)-5-amino-4-[4-[tert-butyl(dimethyl)silyl]oxy-1-oxoisoindolin-2-yl]5-oxopentanoate (275 g, 613 mmol) in methanol ( 2.0 L), tetrabutylammonium fluoride trihydrate (38.7 g, 123 mmol) was added. The mixture was stirred at 18°C for 16 hours. The reaction mixture was evaporated to remove most of the methanol, the residue was dissolved in dichloromethane/water (3 L/2 L), the organic layer was washed with brine (1.0 L), dried over anhydrous sulfate sodium, filtered and evaporated to give the crude product which was purified on a silica gel column to give the product (260 g). The product was added to acetonitrile (750 ml) and the mixture was stirred at 60°C for 2 hours, cooled to 18°C and stirred for a further 2 hours. The solid was filtered and the precipitate was dried to give tert-butyl (4S)-5- amino 4-(4-hydroxy-1-oxoisoindolin-2-yl)-5-oxopentanoate (248 g, 60.5% yield) as a gray solid.

¹ H NMR 400 MHz DMSO-d6 δ: 10.00 (s, 1H), 7.54 (s, 1H), 7.29 (t,J=7.6 Hz, 1H), 7.14 (d, J=4.8 Hz, 2H), 4.72-4.68 (m, 1H), 4.49-4.28 (m, 2H), 2.17-1.97 (m, 4H), 1 .31 (s, 9H).

4-(4-(4-(Chloromethyl)benzyl)piperazin-1 -yl)-3-fluorobenzonitrile.

1,4-bis(Chloromethyl)benzene (51.2 g, 292 mmol) was placed in a flask with acetonitrile (195 ml) and N,Ndimethylformamide (195 ml). The reaction mixture was stirred at ambient temperature until the solids were completely dissolved. Diisopropylamine (51.1 mL, 292 mmol) was then added along with 3-fluoro-4-(piperazin-1-yl)benzonitrile (20 g, 97 mmol). The reaction mixture was heated at 60°C for 1 hour. Acetonitrile was removed under reduced pressure. The remaining mixture was washed with ethyl acetate (1.0 L), water (700 ml) and saline (300 ml). The organic layer was separated and the aqueous layer was extracted twice with ethyl acetate. Volatile organic compounds were removed under reduced pressure. The solid was dissolved in a minimal amount of dichloromethane and purified on a silica gel column (0-100% ethyl acetate in hexane for 3 L). Fractions containing the desired product were combined and volatile organic compounds were removed under reduced pressure. The residue was dissolved in a minimal amount of dichloromethane and purified a second time on a silica gel column (isocratic 10% ethyl acetate in hexane for 800 ml, then 20-80% ethyl acetate in hexane for 4 L). Fractions containing the desired product were combined and VOCs were removed under reduced pressure to give 4-(4-(4-(chloromethyl)benzyl)piperazin-1-yl)-3-fluorobenzonitrile (22.7 g, 66.0 mmol , yield 67.7%) as an off-white solid.

1H NMR (400 MHz, CDCb) δ ppm 7.33-7.39 (m, 5H) 7.29 (d, J=1.96 Hz, 1H) 7.25 (d, J=1.96 Hz, 1H) 6.91 (t, J= 8.56 Hz, 1H) 4.60 (s, 2H) 3.58 (s, 2H) 3.19-3.27 (m, 4 N) 2.58-2.66 (m, 4 N). MS (ESI) m/z 344.2 [M+1]+.

(S)-tert-butyl 5-amino-4-(4-((4-((4-(4-cyano-2-fluorophenyl)piperazin-1-yl)methyl)benzyl)oxy)-1oxoisoindoline-2- yl)-5-oxopentanoate.

(S)-tert-Butyl 5-amino-4-(4-hydroxy-1-oxoisoindolin-2-yl)-5-oxopentanoate (22.05 g, 65.9 mmol) was added to the flask with 4-(4- (4-(chloromethyl)benzyl)piperazin-1-yl)-3-fluorobenzonitrile (22.67 g, 65.9 mmol), potassium carbonate (18.23 g, 132 mmol) and N,N-dimethylformamide (330 ml ). The reaction mixture was heated at 45°C for 16 hours. The reaction mixture was diluted with ethyl acetate (50 ml) and filtered. The filtrate was washed with ethyl acetate (900 ml), water (600 ml) and saline (200 ml). The organic layer was separated and partitioned with water (600 ml). The organic layer was separated and all organic layers were combined, dried over sodium sulfate and volatiles were removed under reduced pressure. The residue was treated with 20% ethyl acetate in hexane and the volatiles were removed under reduced pressure to give (S)-tert-butyl 5-amino-4-(4-((4-((4-(4-cyano-2-fluorophenyl)piperazine -1-yl)methyl)benzyl)oxy)-1-oxoisoindolin-2-yl)-5-oxopentanoate (44.02 g, 68.6 mmol, 104% yield) as a grayish solid. The yield was slightly higher than quantitative, since some N-dimethylformamide remained.

1H NMR (400 MHz, CDCl ₃ ) δ ppm 7.43-7.49 (m, 2H) 7.40 (s, 4H) 7.36 (dd, J=8.38, 1.28 Hz, 1H) 7.29 (d, J=1.96 Hz, 1H) 7.26 (d, J=1.83 Hz, 1H) 7.11 (dd, J=7.64, 1.16 Hz, 1H) 6.92 (t, J=8.50 Hz , 1H) 6.23 (us s, 1H) 5.24-5.32 (m, 1H) 5.15 (s, 2H) 4.86-4.94 (m, 1H) 4.38-4, 55 (m, 2H) 3.61 (s, 2H) 3.18-3.32 (m, 4H) 2.58-2.70 (m, 4H) 2.09-2.47 (m, 4H) 1.43 (s, 8H). MS (ESI) m/z 642.4 [M+1] ⁺ .

- 64 043592 (S)-4-(4-(4-(((2-(2,6-dioxopiperidin-3-yl)-1-oxoisoindolin-4-yl)oxy)methyl)benzyl)piperazin1 -yl) -3-fluorobenzonitrile.

(S)-tert-butyl 5-amino-4-(4-((4-((4-(4-cyano-2-fluorophenyl)piperazin-1-yl)methyl)benzyl)oxy)-1oxoisoindoline-2- yl)-5-oxopentanoate (12.1 g, 18.86 mmol) was added to the vial with acetonitrile (189 ml) and benzenesulfonic acid (3.96 g, 24.51 mmol). The reaction mixture was placed under vacuum and purged with nitrogen. This procedure was repeated once more and the resulting mixture was then heated to 85° C. overnight under a nitrogen atmosphere. The reaction mixture was poured warm directly into 2 separatory funnels containing dichloromethane (1000 ml) and ethyl acetate (300 ml). To this mixture were added saturated sodium hydrogen carbonate solution (900 ml), water (100 ml) and saline solution (450 ml). The organic layer was separated and the aqueous layer was extracted with dichloromethane (800 ml) and ethyl acetate (200 ml). The combined organic layers were dried over anhydrous magnesium sulfate and evaporated. Purification by standard methods yielded the title compound.

¹ H NMR (400 MHz, DMSO-d ₆ ) δ ppm 10.96 (s, 1H) 7.68 (dd, J=13.45, 1.83 Hz, 1H) 7.56 (dd, J=8.44, 1.83 Hz, 1H) 7.43- 7.52 (m, 3H) 7.29-7.39 (m, 4H) 7.11 (t, J=8.80 Hz, 1H) 5.24 (s, 2H) 5.11 (dd, J=13.20, 5.14 Hz, 1H) 4.22-4.46 (m, 2H) 3.54 (s, 2H) 3.12-3.22 (m, 4H) 2.85-2 .97 (m, 1H) 2.53-2.62 (m, 2H) 2.38-2.48 (m, 2H) 1.93-2.03 (m, 1H). MS (ESI) m/z 568.2 [M+1]+.

Example 3. Antibodies to CD3

Preferably, the anti-CD3 antibody comprises a VH variable domain containing the heavy chain CDRs of SEQ ID NO: 1, 2 and 3 as heavy chain CDR1, CDR2 and CDR3, respectively, and a VL variable domain containing the light chain CDR of SEQ ID NO: 4. 5 and 6, respectively, CDR1, CDR2 and CDR3 of the light chain. Preferably, the antibody contains the variable domains of SEQ ID NO: 7 (VH) and SEQ ID NO: 8 (VL). Antibodies to CD3, as described above, were used to generate bispecific antibodies to T cells in accordance with the following example.

Example 4. Production of bispecific antibodies to BCMA/CD3 T cells in a format containing Fc 2+1.

cDNAs encoding the complete heavy and light chains of the corresponding IgG1 antibodies to BCMA, as well as VH and VL cDNAs to CD3, were used as starting materials. For each bispecific antibody, four protein chains were recruited, including the corresponding anti-BCMA antibody heavy and light chains and the anti-CD3 antibody heavy and light chains described above, respectively. To minimize the formation of mispaired heavy chain by-products, such as the two heavy chains of an anti-CD3 antibody, a mutated heterodimeric Fc region carrying knob-to-valve mutations and an engineered disulfide bond is used, as described in WO 2009080251 and WO 2009080252. formation of by-products with unpaired light chains, for example with two light chains of the anti-BCMA antibody, the constant kappa crossover CH1 x is applied to the heavy and light chains of the anti-CD3 antibody using the methods described in WO 2009080251 and WO 2009080252.

a) A BCMA/CD3 T cell bispecific antibody with a 2+1 format, i.e. _{a 2} x bispecific antibody (Fab) that is bivalent for BCMA and monovalent for CD3, would have advantages in terms of potency, predictability of efficacy, and safety because it will preferentially bind to the BCMA target tumor and avoid CD3 antibody uptake, increasing the likelihood of drug exposure to the tumor.

Bispecific antibody to BCMA/CD3 T cells with a 2+1 format, i.e. bispecific antibody (Fab) ₂ x (Fab), which is bivalent for BCMA and monovalent for CD3 with Fc, were produced for previously selected human antibodies to BCMA. cDNAs encoding the complete Fabs (heavy chain VH and CH1 domains plus light chain VL and CL domains) of the corresponding anti-BCMA IgG1 antibodies, as well as anti-CD3 VH and VL cDNAs, were used as starting materials. For each bispecific antibody, four protein chains were used, including the heavy and light chains of the corresponding anti-BCMA antibody and the heavy and light chains of the anti-CD3 antibody described above, with Fc regions, respectively.

Briefly, each bispecific antibody is produced by simultaneous cotransfection of four mammalian expression vectors encoding respectively: a) the full-length light chain cDNA of the corresponding BCMA antibody, b) a fusion cDNA prepared by standard molecular biology techniques such as overlap-splicing-extension PCR encoding the fusion a protein consisting of (in order from N- to C-terminus) a secretory leader sequence, a Fab (VH followed by the CH1 domains) of the corresponding anti-BCMA antibody described above, a flexible glycine (Gly)-serine (Ser) linker with the sequence Gly-Gly-Gly-Gly-Ser-Gly-Gly-Gly-GlySer, Fab (VH followed by CH1 domains) of the corresponding anti-BCMA antibody described above, a flexible glycine(Gly)-serine(Ser) linker with the Gly sequence -Gly-Gly-Gly-Ser-Gly-Gly-Gly-GlySer, VH of the anti-CD3 antibody described above and the constant kappa domain of human light chain cDNA, c) a fusion cDNA prepared by standard molecular biology techniques such as PNR with overlap-splicing and extension, encoding a fusion protein consisting of a secretory leader

- 65 043592 sequence (in order from N- to C-terminus), VL of the anti-CD3 antibody described above, human IgG1 CH1 constant domain cDNA. Cotransfection of mammalian cells and generation and purification of antibodies using the methods described above for the production of human or humanized IgG1 antibodies, with one modification: for antibody purification, the first capture step is not performed using Protein A, but is instead performed using a column such as KappaSelect , for affinity chromatography, filled with a resin that binds to the human kappa light chain constant region (GE Healthcare Life Sciences). In addition, a disulfide can be included to increase stability and yield, as well as additional residues to form ion bridges and increase heterodimerization yields (EP 1870459A1).

To create BCMAxCD3 bispecific antibody vectors, IgG1-derived bispecific molecules consist of at least two antigen-binding moieties capable of specifically binding to two different antigenic determinants CD3 and BCMA. Antigen-binding fragments are Fab fragments consisting of heavy and light chains, each of which contains a variable and a constant region. At least one of the Fab fragments was a Crossfab fragment in which the Fab heavy and light chain constant domains were replaced. The exchange of heavy and light chain constant domains within a Fab fragment ensures that Fab fragments with different specificities do not have identical domain arrangements and therefore do not exchange light chains. The design of the bispecific molecule was monovalent for CD3 and divalent for BCMA, where one Fab fragment was fused to the N-terminus of the internal CrossFab (2+1). The bispecific molecule contained an Fc moiety to have a longer half-life. A schematic representation of the structures is presented in Fig. 1A, 1B, 2A-2D and 3A-3D; the sequences of preferred designs are given in table. 2A. The molecules were produced by cotransfecting HEK293 EBNA cells growing in suspension with mammalian expression vectors using a polymer-based solution. To generate CrossFab-IgG2+1 constructs, cells were transfected with the appropriate expression vectors in a ratio of 1:2:1:1 (Fc vector (overhang): light chain vector: CrossFab light chain vector: heavy chain vector-CrossFab).

Example 5: Combination of Anti-BCMA/CD3 T Cell Bispecific Antibody with Compound

T cell activation and cytokine release.

Purified T cells are thawed in RPMI 1640 medium containing 10% FBS and 1 ng/ml human IL-7. Cells are counted on a Vi-CELL cell counter and diluted with cell medium to 2x106 cells/ml. T cells are recovered in a 5% CO ₂ incubator at 37°C overnight. T cells are treated with a bispecific antibody that specifically binds to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein, or Compound 1, Compound 2, or Compound 3 as a single agent or in combination, for 24, 48 and 72 hours. Cells were collected at each time point and analyzed by FACS analysis for markers of T cell activation (CD25, CD69, and HLA-DR) on the CD3+ CD4+ and CD3+ CD8+ subsets. Culture media were also collected at each time point and analyzed for cytokines using the MesoScale Discovery or Luminex platforms.

Co-cultures of effector T cells (E) and tumor cells (T). T cells and/or tumor cells pretreated with specific binding to human B cell maturation antigen (BCMA) and human CD3ε (CD3) provided herein, either with one agent or a combination of Compound 1, Compound 2, or Compound 3, are cocultured together with different E:T ratios at 37°C, 5% CO ₂ and assessed after 24, 48 or 72 h for T cell-induced tumor killing using FACS assays. Tumor cells were labeled with CFSE (5(6)-carboxyfluorescein N -hydroxysuccinimidyl ester) according to the manufacturer's instructions immediately before starting the coculture assay. In addition, markers of T cell activation (CD25, CD69, HLA-DR) are monitored by FACS on CD3+ CD4+ and CD3+ CD8+ subsets.

In one embodiment, the combination treatment demonstrates increased depth of response in cells resistant to lenalidomide and/or pomalidomide compared to either agent alone. In another embodiment, the combination treatment demonstrates synergistic and/or additive activity in killing myeloma cells with low or no BCMA expression. In addition, combination treatment demonstrates an increase in T cell activation and cytokine production (such as IL-2, IFN-gamma, and TNF-alpha) compared with a single agent alone.

Example 6: Combination of Anti-BCMA/CD3 T Cell Bispecific Antibody with Compound

Co-culture of effector T cells (E) and target cells (T) after pretreatment with compounds.

CD3+ T cells were isolated from peripheral blood mononuclear cell fractions from healthy

- 66 043592 donors using magnetically activated cell sorting. Cells were thawed in RPMI 1640 culture medium supplemented with 10% (v/v) fetal bovine serum (FBS), nonessential amino acids, and sodium pyruvate. All cell cultures and cell treatments were performed in a 37°C, 5% CO2 incubator for the indicated time periods. T cells were then labeled with CFSE (carboxyfluorescein succinimidyl ester) according to the manufacturer's instructions and allowed to recover overnight in the presence of 1 ng/ml human IL-7. T cells were treated with DMSO (control) or compound 2 as sole agent for 16 hours before coculture. Multiple myeloma cell lines H929 and OPM-2 or plasma cell leukemia (PCL) cell line L363 were labeled with CellTrace™ violet dye, then pretreated with DMSO (control) or compound 2 as a single agent for 72 hours. Then T cells and cells -targets were washed to remove compounds and cocultured in the presence of increasing concentrations of bispecific antibody that specifically binds to human B-cell maturation antigen (BCMA) and human CD3ε (CD3), as proposed herein, for 72 hours at various effector ratios T cells (E) and target cells (T). Cells were harvested at the end of coculture to analyze target cell apoptosis and necrosis by flow cytometry using the Annexin V APC Apoptosis Detection Kit with 7-AAD, following the manufacturer's directions (BioLegend). The results demonstrated that pretreatment of target cells with Compound 2 significantly increased the effectiveness of the bispecific antibody (for both H929 and L363 cells), as well as the maximum target cell killing (for H929 cells) induced by the bispecific antibody, as shown in the test (Figs. 4A and 4B). In cytotoxicity assays with OPM-2 cells, results showed that treatment of either effector T cells or target cells only with Compound 2 increased the potency and target cell killing efficiency of the bispecific antibody when tested (Fig. 4C). For OPM-2 cytotoxicity assays, the combination of effector T cell pretreatment and target cell pretreatment with Compound 2 resulted in the greatest enhancement and increase in bispecific antibody efficacy when tested (Figure 4C).

Co-culture of effector T cells (E) and target cells (T) with simultaneous treatment with compounds.

CD3+ T cells were isolated from peripheral blood mononuclear cell fractions from three different healthy donors (Donors A, B, and C) using magnetically activated cell sorting. Cells were thawed in RPMI 1640 culture medium supplemented with 10% (v/v) FBS, nonessential amino acids, sodium pyruvate, and penicillin/streptomycin. All cell cultures and treatments were performed in a 37°C, 5% CO ₂ incubator for the indicated time periods. T cells were then labeled with CFSE (carboxyfluorescein succinimidyl ester) according to the manufacturer's instructions and allowed to recover overnight in the presence of 1 ng/ml human IL-7. The multiple myeloma cell line H929 was labeled with CellTrace™ violet dye and recovered overnight. T cells and target cells were then washed and cocultured in the presence of increasing concentrations of bispecific antibodies specifically binding to human B-cell maturation antigen (BCMA) and human CD3ε (CD3), presented herein, for 72 hours at a fixed temperature. temperature, ratio of effector T cells (E) to target cells (T) 1:3. Co-culture in the presence of bispecific antibodies was performed in the presence of DMSO (control) or compound 2. Cells were collected at the end of co-culture for analysis of apoptosis and necrosis of target cells by flow cytometry using the Annexin V APC Apoptosis Detection Kit with 7-AAD. The results demonstrated that for all donors tested, simultaneous exposure of cells to Compound 2 significantly increased the effectiveness of the bispecific antibody when tested, and also improved the maximum efficiency of target cell killing mediated by the bispecific antibody (Fig. 5).

Example 7: Combination of anti-BCMA/CD3 T cell bispecific antibody with compound in lenalidomide-resistant multiple myeloma

Co-culture of effector T cells (E) and lenalidomide-resistant multiple myeloma target cells (T) after pretreatment with compounds.

CD3+ T cells were isolated from peripheral blood mononuclear cell fractions from three different healthy donors (donors D, E, and F) using magnetically activated cell sorting. Cells were thawed in RPMI 1640 culture medium supplemented with 10% (v/v) fetal bovine serum (FBS), nonessential amino acids, sodium pyruvate, and penicillin/streptomycin. All cell cultures and cell treatments were performed in a 37°C, 5% CO ₂ incubator for the indicated periods of time. T cells were then labeled with CFSE (carboxyfluorescein succinimidyl ester) according to the manufacturer's instructions and allowed to recover overnight in the presence of 1 ng/ml human IL-7. The lenalidomide-resistant multiple myeloma cell line H929-1051 was obtained by long-term cultivation in the presence of increasing concentrations of

-

Claims (18)

tions of lenalidomide as described previously (Ghandi et al. Br. J. Haematol. 2014 Jan; 164(2):233-44) using the methods described (Lopez-Girona et al. Leukemia. 2012 Nov;26(11):2326 -35). H929-1051 cells were labeled with CellTrace™ violet dye, then pretreated with DMSO (control), pomalidomide, or Compound 2 as a single agent for 72 hours. T cells and target cells were then washed to remove compound and cocultured in the presence of increasing concentrations of bispecific antibodies , specifically binding to human B cell maturation antigen (BCMA) and human CD3ε (CD3), presented herein, for 72 hours at a fixed temperature, ratio of effector T cells (E) to target cells (T) 1:3 . Cells were harvested at the end of coculture to analyze target cell apoptosis and necrosis by flow cytometry using the APC Annexin V Apoptosis Detection Kit with 7AAD, following the manufacturer's directions (BioLegend). The results demonstrated that pretreatment of lenalidomide-resistant H929-1051 target cells with Compound 2, but not pretreatment with pomalidomide, increased the potency and maximum target cell killing induced by the bispecific antibody when tested (Figure 6). Data suggest that this cell line is also resistant to pomalidomide. The embodiments described above are intended to be examples only and those skilled in the art will recognize or be able to ascertain, using no more than routine experimentation, numerous equivalents of specific compounds, materials, and techniques. Such equivalents are intended to be included within the scope of this invention and are covered by the appended claims. CLAIM 1. A method of treating multiple myeloma, comprising administering to a patient in need thereof a therapeutically effective amount of a compound of formula 1 or an enantiomer, mixture of enantiomers, tautomer, isotopologue or pharmaceutically acceptable salt thereof; in combination with a bispecific antibody comprising a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA) and a second binding moiety that specifically binds to human CD3ε (CD3), wherein said first binding moiety comprises a VH region containing a CDR1H region with SEQ ID NO: 21, a CDR2H region with SEQ ID NO: 22 and a CDR3H region with SEQ ID NO: 17, and a VL region containing a CDR3L region with SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group: i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28. 2. A method of treating multiple myeloma, comprising administering to a patient in need thereof an effective amount of a compound of formula 2 or a tautomer, isotopologue or pharmaceutically acceptable salt thereof; in combination with a bispecific antibody comprising a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA) and a second binding moiety that specifically binds to human CD3ε (CD3), wherein said first binding moiety comprises a VH region containing a CDR1H region with SEQ ID NO: 21, a CDR2H region with SEQ ID NO: 22 and a CDR3H region with SEQ ID NO: 17, and a VL region containing a CDR3L region with SEQ ID NO: 20, and a combination of CDR1L and CDR2L regions selected from the group: i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28. 3. The method according to claim 1 or 2, wherein the multiple myeloma is relapsed, refractory or resistant. - 68 043592 4. The method of claim 3, wherein the multiple myeloma is refractory or resistant to lenalidomide. 5. The method of claim 3, wherein the multiple myeloma is refractory or resistant to pomalidomide. 6. The method of claim 1 or 2, wherein the multiple myeloma is newly diagnosed multiple myeloma. 7. The method according to claim 1 or 2, wherein multiple myeloma is a plasma cell leukemia. 8. The method according to any one of claims 1 to 7, wherein the compound is administered before the administration of the bispecific antibody. 9. The method according to any one of claims 1 to 7, wherein the compound is administered simultaneously with the bispecific antibody. 10. The method according to any one of claims 1 to 7, wherein the compound is administered after administration of the bispecific antibody. 11. The method according to any one of claims 1 to 10, further comprising the introduction of an additional active agent. 12. Use of the compound of formula 1 o or an enantiomer, a mixture of enantiomers, a tautomer, an isotopologue, or a pharmaceutically acceptable salt thereof, in combination with a bispecific antibody comprising a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA) and a second binding moiety that specifically binds to human CD3ε (CD3 ), wherein said first binding portion comprises a VH region comprising a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17, and a VL region comprising a CDR3L region of SEQ ID NO: : 20, and a combination of CDR1L and CDR2L regions selected from the group: i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28, for the treatment of multiple myeloma. 13. Use of the compound of formula 2 o or a tautomer, isotopologue, or pharmaceutically acceptable salt thereof in combination with a bispecific antibody comprising a first binding moiety that specifically binds to human B-cell maturation antigen (BCMA) and a second binding moiety that specifically binds to human CD3ε (CD3), said first the binding part comprises a VH region containing a CDR1H region of SEQ ID NO: 21, a CDR2H region of SEQ ID NO: 22 and a CDR3H region of SEQ ID NO: 17, and a VL region containing a CDR3L region of SEQ ID NO: 20, and a combination areas CDR1L and CDR2L, selected from the group: i) the CDR1L region of SEQ ID NO: 23 and the CDR2L region of SEQ ID NO: 24, ii) the CDR1L region of SEQ ID NO: 25 and the CDR2L region of SEQ ID NO: 26, or iii) the CDR1L region of SEQ ID NO: 27 and the CDR2L region of SEQ ID NO: 28, for the treatment of multiple myeloma. 14. Use according to claim 12 or 13, wherein the multiple myeloma is relapsed, refractory or resistant. 15. Use according to claim 14, wherein the multiple myeloma is refractory or resistant to lenalidomide. 16. Use according to claim 14, wherein the multiple myeloma is refractory or resistant to pomalidomide. 17. Use according to claim 12 or 13, wherein the multiple myeloma is newly diagnosed multiple myeloma. 18. Use according to claim 12 or 13, wherein multiple myeloma is a plasma cell leukemia -