EP4698178A2 - Treatment of non-small cell lung cancer - Google Patents

Abstract

The present invention provides methods for treating non-small cell lung cancer.

Description

TREATMENT OF NON-SMALL CELL LUNG CANCER CROSS-REFERENCE TO RELATED APPLICATIONS [0001] This application claims priority under 35 U.S.C. § 119(e) to U.S. provisional application, U.S. S.N.63/497,627, filed April 21, 2023, which is incorporated herein by reference. FEDERALLY SPONSORED RESEARCH AND DEVELOPMENT [0002] This invention was made with government support under contract numbers R01CA116020, R35CA197568, and 5P01CA154303 awarded by the National Institutes of Health. The government has certain rights in the invention. BACKGROUND [0003] Lung cancer is the second most common cancer worldwide but the leading cause of cancer-related death. Approximately 80-85% of all lung cancers are non- small cell lung cancer (NSCLC) and the main subtypes are adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Epidermal growth factor receptor (EGFR) mutations are the most common genetic alteration in non-smoking related lung cancer and these mutations are more prevalent among east Asians and Native Americans, 49%, as compared to people with European ancestry, 10-15%. Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) are the standard of care in EGFR-mutant lung cancers and have increased the survival rates of patients with NSCLC. Unfortunately, almost all patients develop resistance, which leads to therapeutic failure. [0004] Further, approximately 20-30% of human lung adenocarcinomas have a mutation in Kelch-like ECH-associated protein 1 (KEAP1), a negative regulator of NFE2L2 (NRF2). KEAP1 mutations are associated with poor survival rates. Cancers with KEAP1 mutations have been found to be selectively dependent on the gene, SLC33A1, which encodes a solute carrier (SLC) that transports acetyl-CoA, which functions to maintain proteostasis in the endoplasmic reticulum. A dysfunctional KEAP1-NRF2 interaction is involved in osimertinib resistance in lung cancer and thus, the KEAP1/NRF2 pathway plays an important role in osimertinib resistance. See Foggetti et al., Cancer Discov (2021) 11 (7): 1736–1753; Hellyer et al., Lung Cancer 134 (2019) 42–45. [0005] First-generation EFGR-TKIs, such as erlotinib, gefitinib, and icotinib, and second-generation EGFR-TKIs, such as afatinib and dacomitinib, develop acquired resistance after a median period of 10-14 months. See Shou, et al., Cancer Letters 379 (2016) 124-133. Osimertinib, a third-generation mutation-selective EFGR-TKI has become the standard of care for EGFR-mutant NSCLC patients with acquired resistance to first- or second-generation EGFR-TKIs related to the T790M mutation. Unfortunately, resistance will eventually emerge even for osimertinib. After osimertinib resistance emerges, oncologists often resort to standard chemotherapy, newer generation TKIs, immune checkpoint inhibitors, or combinations of said therapies. See Schmid, et al, Lung Cancer 147 (2020) 123-129 for a discussion of the mechanisms of osimertinib resistance and emerging treatment options. [0006] There is accumulating evidence that acquired resistance to EGFR-TKIs require an intermediary step, in which a small subset of tumor cells survive treatment. It is thought that these cells, often dubbed as cancer “persister” cells, eventually acquire additional alterations that enable them to become fully resistant through EGFR on- or off- target mechanisms hence successful targeting of EGFR-TKI persister cells has the potential to significantly delay or prevent disease progression. Today, there are no therapies to delay or circumvent the acquired resistance to osimertinib. [0007] Thus, there is a need to identify novel combination therapies that will increase the therapeutic power of osimertinib by eliminating residual disease and delay or prevent emergence of resistance.

SUMMARY [0008] There is provided a method of treating non-small cell lung cancer (NSCLC) in a patient in need thereof comprising administering an effective amount of osimertinib, or a pharmaceutically acceptable salt thereof, and an effective amount of a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof to a patient in need thereof. [0009] There is also provided a method for treating a patient having a KEAP1/NRF2/CUL3 mutant tumor (e.g., treating the KEAP1/NRF2/CUL3 mutant tumor in the patient) comprising administering an effective amount of a cyclophilin inhibitor or a pharmaceutically acceptable salt thereof. [0010] There is also provided a method for treating non-small cell lung cancer (NSCLC) in a patient having elevated glutathione comprising administering an effective amount of osimertinib or a pharmaceutically acceptable salt thereof, and an effective amount of a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof. [0011] There is also provided a method of sensitizing cancer cells to treatment by an EGFR inhibitor comprising inhibiting SLC33A1. [0012] There is also provided a method of treating non-small cell lung cancer (NSCLC) in a patient in need thereof comprising inhibiting SLC33A1 and administering an effective amount of an EGFR inhibitor, or a pharmaceutically acceptable salt thereof. [0013] There is also provided pharmaceutical composition comprising osimertinib, or a pharmaceutically acceptable salt thereof, and a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof, and one or more pharmaceutically acceptable carriers, diluents, or excipients.

BRIEF DESCRIPTION OF DRAWINGS [0014] FIG.1 shows that SLC33A1 knockout can sensitize PC9 cells overexpressing some EGFR variants known to confer resistance to osimertinib including L858R, L858R/L718V, R222C and L858R/C797S. Error bars in all figures represent standard deviations. [0015] FIG.2 shows SLC33A1 knockout can re-sensitize PC9 persister cells to osimertinib. [0016] FIG.3 shows average osimertinib IC50 calculated from re-sensitized PC9 persister cells (one-way Anova) with N.S. representing P > 0.05, * representing P ≤ 0.05, ** representing P ≤ 0.01, *** representing P ≤ 0.001 and **** representing P ≤ 0.0001. [0017] FIG.4 shows the synergy between osimertinib and CsA. [0018] FIG.5 shows CsA treatment sensitizes PC9, HCC827, NCI-H1975 or NCI- H3255 cell lines to osimertinib. [0019] FIG.6 shows CsA treatment re-sensitizes PC9R to osimertinib. [0020] FIG.7 shows multiple other cyclophilin inhibitors that have similar effect to CsA in sensitizing PC9 cells to osimertinib. [0021] FIG.8 shows sensitizing effect of CsA in PC9/PC9R and NCI-H1975/R. [0022] FIG.9 shows the comparison between single agent osimertinib to the combination of osimertinib with either CsA or NIM811 in-vivo. Bottom panel shows statistically significant tumor volume between osimertinib alone or in combination with CsA or NIM811, at different time points (14 days, 24 days, 31 days). (one-way Anova). [0023] FIG.10 shows the results of a CRISPR screen for genes that can modify the activity of CsA. These results show that same genes that cause sensitivity to CsA also cause sensitivity to SLC33A1 knockout, thereby providing another functional link between CsA and SLC33A1. FIG.10A highlights Glutamate-Cysteine Ligase Modifier Subunit (GCLM), Glutamate-Cysteine Ligase Catalytic Subunit (GCLC) and Glutathione Synthetase (GSS) are associated with resistance. FIG.10B shows the roles of GCLM, GCLC and GSS in conversion of L-Cysteine to glutathione (GSH). DETAILED DESCRIPTION [0024] Osimertinib, an irreversible EFGR-TKI, is a well-known drug sold in the United States under the name TAGRISSO® with the chemical name of N-(2-{2- dimethylaminoethyl-methylamino}-4-methoxy-5-{[4-(1-methylindol-3-yl)pyrimidin- 2-yl]amino}phenyl)prop-2-enamide. It is regularly used as a salt, specifically the mesylate salt, and salts are included in the term osimertinib as used herein. Osimertinib is indicated as an adjuvant therapy after tumor resection in adult patients with NSCLC and the first line treatment of adult patients with metastatic NSCLC whose tumors have EGFR exon 19 deletions or exon 21 L858R mutations. Additionally, osimertinib is indicated for the treatment of adult patients with metastatic EGFR T790M mutation-positive NSCLC whose disease has progressed on or after EGFR-TKI therapy. Unfortunately, patients develop a resistance to osimertinib. [0025] The cyclophilin family of proteins are overexpressed in several cancers and have emerged as potential drug targets based on their involvement in cancer cell activities, such as protein folding, proliferation, and cell cycle regulation; cyclophilin expression is correlated to poor outcomes for cancer patients. Cyclophilin inhibitors are known in the art and include the cyclic peptide, cyclosporine A (CsA) and its analogs, including NIM811 [also known as (melle-4)cyclosporin; N-methyl-4- isoleucine-cyclosporin; and (3S,6S,9S,12R,15S,18S,21S,24S,30S,33S)-24-[(2S)-butan- 2-yl]-30-ethyl-33-[(E,1R,2R)-1-hydroxy-2-methylhex-4-enyl]- 1,4,7,10,12,15,19,25,28-nonamethyl-6,9,18-tris(2-methylpropyl)-3,21-di(propan-2- yl)-1,4,7,10,13,16,19,22,25,28,31-undecazacyclotritriacontane- 2,5,8,11,14,17,20,23,26,29,32-undecone], alisporivir [also known as (3S,6S,9S,12R,15S,18S,21S,24S,27R,30S,33S)-25,30-diethyl-33-[(E,1R,2R)-1- hydroxy-2-methylhex-4-enyl]-1,4,7,10,12,15,19,27,28-nonamethyl-6,9,18-tris(2- methylpropyl)-3,21,24-tri(propan-2-yl)-1,4,7,10,13,16,19,22,25,28,31- undecazacyclotritriacontane-2,5,8,11,14,17,20,23,26,29,32-undecone], and voclosporin [also known as (3S,6S,9S,12R,15S,18S,21S,24S,30S,33S)-30-ethyl-33- [(1R,2R,4E)-1-hydroxy-2-methylhepta-4,6-dienyl]-1,4,7,10,12,15,19,25,28- nonamethyl-6,9,18,24-tetrakis(2-methylpropyl)-3,21-di(propan-2-yl)- 1,4,7,10,13,16,19,22,25,28,31-undecazacyclotritriacontane- 2,5,8,11,14,17,20,23,26,29,32-undecone]. Other cyclophilin inhibitors are known in the art. See WO 2021/190603. [0026] CsA, a cyclic undecapeptide, is a well-known drug with the chemical name of (3S,6S,9S,12R,15S,18S,21S,24S,30S,33S)-30-ethyl-33-[(E,1R,2R)-1-hydroxy-2- methylhex-4-enyl]-1,4,7,10,12,15,19,25,28-nonamethyl-6,9,18,24-tetrakis(2- methylpropyl)-3,21-di(propan-2-yl)-1,4,7,10,13,16,19,22,25,28,31- undecazacyclotritriacontane-2,5,8,11,14,17,20,23,26,29,32-undecone; it was first approved in 1983. Generally, CsA is regarded as an immunosuppressive agent used to treat organ rejections after transplants as well as other autoimmune diseases, such as rheumatoid arthritis (RA), psoriasis, amyotrophic lateral sclerosis, nephrotic syndrome, and graft versus host disease (GVHD). Also see Matsuda and Koyasu, Immunopharmacology 47, 2-3 (2000), 119-125 for a discussion of the mechanisms of action of cyclosporine. [0027] Furthermore, dysfunction in the KEAP1-NRF2 pathway plays an important role in osimertinib resistance. Lung cancer cells with KEAP1 mutations are sensitive to glutaminase inhibitors. Further, cells that have aberrant regulation of KEAP1- NFR2 are particularly sensitive to targeting of SCL33A1. Moreover, the loss of SLC33A1 activity can be rescued by inhibiting glutathione synthesis and/or removing excess accumulation of glutathione. Therefore, the reduction of glutathione levels using buthionine sulfoximine (BSO) rescues the sensitization effect to osimertinib. [0028] There is provided a method for treating non-small cell lung cancer (NSCLC) in a patient in need thereof comprising administering an effective amount of osimertinib, or a pharmaceutically acceptable salt thereof, and an effective amount of a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof. In a preferred embodiment, the cyclophilin inhibitor is selected from a group comprising cyclosporine A, NIM811, alisporivir, or voclosporin, or a pharmaceutically acceptable salt thereof. In a more preferred embodiment, the cyclophilin inhibitor is cyclosporine A, or a pharmaceutically acceptable salt thereof. [0029] There is also provided a method for treating a patient having a KEAP1/NRF2/CUL3 mutant tumor (e.g., treating the KEAP1/NRF2/CUL3 mutant tumor in the patient) comprising administering an effective amount of a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof. In a preferred embodiment, the cyclophilin inhibitor is selected from a group comprising cyclosporine A, NIM811, alisporivir, or voclosporin, or a pharmaceutically acceptable salt thereof. In a more preferred embodiment, the cyclophilin inhibitor is cyclosporine A, or a pharmaceutically acceptable salt thereof. In another embodiment, the method further comprises the administration of an effective amount of osimertinib, or a pharmaceutically acceptable salt thereof. [0030] There is also provided a method for treating non-small cell lung cancer (NSCLC) in a patient having elevated glutathione comprising administering an effective amount of osimertinib, or a pharmaceutically acceptable salt thereof, and an effective amount of a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof. In a preferred embodiment, the cyclophilin inhibitor is selected from a group comprising cyclosporine A, NIM811, alisporivir, or voclosporin, or a pharmaceutically acceptable salt thereof. In a more preferred embodiment, the cyclophilin inhibitor is cyclosporine A, or a pharmaceutically acceptable salt thereof. In another embodiment, the method further comprises the administration of an effective amount of a glutathione synthesis inhibitor, or a pharmaceutically acceptable salt thereof. [0031] There is also provided a method of sensitizing cancer cells to treatment by EGFR-TKIs comprising inhibiting SLC33A1. In a preferred embodiment, the EGFR- TKI is osimertinib, gefitinib, erlotinib, icotinib, afatinib or dacomitinib, or a pharmaceutically acceptable salt thereof. [0032] There is also provided a method for treating non-small cell lung cancer (NSCLC) in a patient in need thereof comprising inhibiting SLC33A1 and administering an effective amount of an EGFR-TKI, or a pharmaceutically acceptable salt thereof. In a preferred embodiment, the EGFR-TKI is osimertinib, gefitinib, erlotinib, icotinib, afatinib or dacomitinib, or a pharmaceutically acceptable salt thereof. [0033] There is also provided a pharmaceutical composition comprising osimertinib, or a pharmaceutically acceptable salt thereof, and a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof, and one or more pharmaceutically acceptable carriers, diluents, or excipients. In a preferred embodiment, the cyclophilin inhibitor is selected from a group comprising cyclosporine A, NIM811, alisporivir, or voclosporin, or a pharmaceutically acceptable salt thereof. In a more preferred embodiment, the cyclophilin inhibitor is cyclosporine A, or a pharmaceutically acceptable salt thereof. In a particular embodiment, the composition further comprises one or more other therapeutic agents. [0034] Further, there is also provided osimertinib, or a pharmaceutically acceptable salt thereof, and a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof, for use in therapy, in particular for the treatment of NSCLC. In a preferred embodiment, the cyclophilin inhibitor is selected from a group comprising cyclosporine A, NIM811, alisporivir, or voclosporin, or a pharmaceutically acceptable salt thereof. In a more preferred embodiment, the cyclophilin inhibitor is cyclosporine A, or a pharmaceutically acceptable salt thereof. [0035] There is also provided the use of osimertinib, or a pharmaceutically acceptable salt thereof, and a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for the treatment of NSCLC. In a preferred embodiment, the cyclophilin inhibitor is selected from a group comprising cyclosporine A, NIM811, alisporivir, or voclosporin, or a pharmaceutically acceptable salt thereof. In a more preferred embodiment, the cyclophilin inhibitor is cyclosporine A, or a pharmaceutically acceptable salt thereof. [0036] Cyclophilin inhibitors are also provided, defined as a compound means for inhibiting cyclophilin. Such compound means include compounds from Schiene- Fischer et al. Angew Chem Int Ed Engl.2022 Sep 26;61(39):e202201597 and equivalents thereof. For the purposes of defining the compounds falling within such compound means, the function is inhibiting cyclophilin. Such compound are organic compounds that are cyclic polypeptides with a molecular weight less than 1500 and may inhibit cyclophilin by binding a variety of binding sites but does so through direct molecular interaction between the compound and cyclophilin. The result is inhibition of cyclophilin to a degree sufficient to increase the sensitivity of a tumor cell to osimertinib. [0037] Also provided are cyclophilin inhibitors defined as a compound means for inhibiting SLC33A1. Such compound means include compounds from Schiene- Fischer et al. Angew Chem Int Ed Engl.2022 Sep 26;61(39):e202201597 and equivalents thereof. For the purposes of defining the compounds falling within such compound means, the function is inhibiting SLC33A1. Such compound are organic compounds that are cyclic polypeptides with a molecular weight less than 1500 and may inhibit SLC33A1 by binding a variety of binding sites but does so through direct molecular interaction between the compound and SLC33A1. The result is inhibition of SLC33A1 to degree sufficient to increase the sensitivity of a tumor cell to osimertinib. [0038] In the present methods, osimertinib may be administered as a pharmaceutically acceptable salt. Pharmaceutically acceptable salts and common methodology for preparing them are well known in the art. See, e.g., P. Stahl, et al. Handbook of Pharmaceutical Salts: Properties, Selection and Use, 2nd 30 Revised Edition (Wiley-VCR, 2011); S. M. Berge, et al., "Pharmaceutical Salts," Journal of Pharmaceutical Sciences, Vol.66, No.1, Jan.1977. Preferred salts of the disclosure include erlotinib hydrochloride, osimertinib mesylate, neratinib maleate, afatinib dimaleate, and mobocertinib succinate. [0039] Cyclophilin inhibitors may be administered as a pharmaceutically acceptable salt. Pharmaceutically acceptable salts and common methodology for preparing them are well known in the art. See, e.g., P. Stahl, et al. Handbook of Pharmaceutical Salts: Properties, Selection and Use, 2nd 30 Revised Edition (Wiley-VCR, 2011); S. M. Berge, et al., "Pharmaceutical Salts," Journal of Pharmaceutical Sciences, Vol.66, No.1, Jan.1977. [0040] Osimertinib and cyclophilin inhibitors are preferably formulated as pharmaceutical compositions administered by a variety of routes. Such pharmaceutical compositions and processes for preparing the same are well known in the art. See, e.g., Remington: The Science and Practice of Pharmacy(I) (A. Gennaro, et al., eds., 21st ed., Mack Publishing Co., 2005). [0041] Osimertinib, cyclophilin inhibitors, and other compounds included in the methods of the present disclosure, or salts thereof, may be prepared by a variety of procedures known in the art or are commercially available. Osimertinib (S7297) and Cyclosporine A (S2286) were purchased at SelleckChem (https://www.selleckchem.com/). NIM811 (HY-P0025) and alisporivir (HY-12559) were purchased at MedChemExpress (https://www.medchemexpress.com/). Voclosporin (SML 3108) and L-buthionine sulfoximine (B2525) were purchased at Millipore Sigma (https://www.sigmaaldrich.com/US/en). [0042] The dosage and administration of osimertinib are known. For adjuvant treatment of early-stage NSCLC, 80 mg of osimertinib is given once daily with or without food until disease recurrence, or unacceptable toxicity, or for up to three years. For metastatic NSCLC, 80 mg of osimertinib is given orally once daily, with or without food, until disease progression or unacceptable toxicity. For patients who have difficulty swallowing solids, osimertinib tablet(s) may be dispersed in 60 mL of non-carbonated water only. Additionally, for administration via nasogastric tube, osimertinib tablet(s) may be dispersed in 15 mL of non-carbonated water followed by an additional 15 mL of water to transfer any residues in the syringe. In some instances, dosage levels below the lower limit of the aforesaid dose amount may be more than adequate, while in other cases still larger doses may be employed without causing any harmful side effect, and therefore the above dosages are not intended to limit the scope of the invention in any way. The optimum dose for each patient, as always, must be set by the physician in charge, taking into account the patient’s size, other medications which the patient requires, the severity of the disorder, and all of the other circumstances of the patient. [0043] The dosage and administration of CsA are known. Cyclosporine A is available in the following dosage forms: oral capsule, oral solution, intravenous/injectable, and ophthalmic emulsion. The dosages of cyclosporine can be variable depending on the patient and the disease state. For adult organ transplant patients, a single oral dose of 14 to 18 mg/kg is given four to twelve hours pre- transplant followed by 5 to 15 mg/Kg orally per day divided into two doses. The dosage is then reduced by 5% per week until a dose of 5 to 10 mg/Kg orally divided into two doses has been reached. For adults with RA and psoriasis, the maximum dose is 4 mg/kg daily. In some instances, dosage levels below the lower limit of the aforesaid range may be more than adequate, while in other cases still larger doses may be employed without causing any harmful side effect, and therefore the above dosage range is not intended to limit the scope of the invention in any way. The optimum dose for each patient, as always, must be set by the physician in charge, taking into account the patient’s size, other medications which the patient requires, the severity of the disorder, and all of the other circumstances of the patient. The optimum dose for each patient, as always, must be set by the physician in charge, taking into account the patient’s size, other medications which the patient requires, the severity of the disorder, and all of the other circumstances of the patient. [0044] As used herein, the term “treating” (or “treat” or “treatment”) refers to restraining, slowing, stopping, or reversing the progression or severity of an existing symptom, condition, or disorder. [0045] As used herein, the phrase "effective amount" means an amount of a compound that is sufficient to treat in one or more doses a condition or detrimental effect thereof herein described or an amount of a compound that is sufficient to inhibit EGFR, cyclophilin, KEAP1, or SCL33A1 to achieve the objectives described herein. [0046] As used herein, the phrase “administering” (or “administer” or “administration”) means the act of giving a compound or the direct application of a compound by ingestion, inhalation, injection, or any other means, to the body of a patient. Two or more compounds disclosed herein may be administered in combination or separately, and if separately, simultaneously or sequentially over a period of time as determined by a qualified care giver. [0047] As used herein, "patient" refers to a mammal, preferably a human, more preferably a human with a cancer that has become resistant to osimertinib. [0048] As used herein, the term “epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI)” or “EFGR inhibitor” refers to a well-established class of compounds that inhibit EGFR. Examples of EGFR inhibitor include erlotinib (sold in the United States as TARCEVA®), gefitinib (sold in the United States as IRESSA®), osimertinib (sold in the United States as TAGRISSO®), neratinib (sold in the United States as NERLYNX®), dacomitinib (sold in the United States as VIZIMPRO®), afatinib (sold in the United States as GILOTRIF®), and mobocertinib (sold in the United States as EXKIVITY®). Erlotinib and gefitinib are reversible inhibitors of EGFR. Osimertinib, neratinib, dacomitinib, afatinib, and mobocertinib are irreversible inhibitors of EGFR. Preferred EGFR-TKIs are osimertinib, gefitinib, erlotinib, icotinib, afatinib and dacomitinib. The most preferred EGFR-TKI is osimertinib. [0049] The following documents are incorporated by reference: US Pat No 5,747,498 related to erlotinib; US Pat No 5,457,105A and US Pat No 5,770,599 related to gefitinib; US Pat No 8,946,235, US Pat No 9,732,058, and 11,524,951 related to osimertinib; US Pat No 7,399,865 related to neratinib; US Pat No 7,772,243 related to dacomitinib; US Pat No 8426586 and US Patent No RE43431 related to afatinib; and US Pat No 9,796,712 and US Pat No 10,227,342. [0050] As used herein, the term “cyclophilin inhibitor” refers to a well-established class of compounds that inhibit cyclophilin. Preferred cyclophilin inhibitors are cyclosporine A (CsA), N-methyl-4-isoleucine-cyclosporin (NIM811), alisporivir, and voclosporin. The most preferred cyclophilin inhibitor is CsA. [0051] The following documents are incorporated by reference: US Pat No 4,117,118 and US Patent Application No 2004/0121944 related to CsA. [0052] As used herein, the term “a glutathione synthesis inhibitor” refers to a well- established class of compounds that inhibit glutathione synthesis. [0053] As used herein, “KEAP1/NRF2/CUL3 mutant tumor” refers to tumors that have genetic alterations in the KEAP1 (Kelch-like ECH-associated protein 1)-NRF2 (nuclear factor erythroid 2 like 2)-CUL3 (cullin 3) axis which leads to tumorigenesis and drug resistance in many cancers, including non-small cell lung cancer (NSCLC). [0054] As used herein, the term “elevated glutathione” refers to an increase of the levels of the tripeptide, γ-l-glutamyl-l-cysteinyl-glycine, typically known as glutathione (GSH), caused by augmented oxidative stress known to occur in cancer cells or by other mechanisms, including genetic alterations in the KEAP1/NRF2/CUL3 axis. [0055] As used herein, the term “inhibiting SLC33A1” refers to deactivating or knocking out the activity of SLC33A1 through known methods of genetic targeting, such as CRISPR. [0056] As used herein, the phrase “drug resistance” or “chemoresistance” means the ability of cancer cells to circumvent, survive and proliferate in face of a treatment that would otherwise cause cell cycle arrest, senescence, or cell death. [0057] As used herein, the phrase “resistance rescue” means the ability of a chemotherapeutic agent to overcome chemoresistance and again provide some or all anti-cancer effect. [0058] As used herein, the phrase “persister cells” means any subset of tumor cells that survive treatment and eventually acquire additional alterations that enable them to become fully resistant through EGFR on- or off-target mechanisms. [0059] The abbreviations used herein are defined according to Aldrichimica Acta, Vol.17, No.1, 1984. Other abbreviations are defined as follows: “DMEM” refers to Dulbecco’s Modified Eagle Medium; “PBS” refers to phosphate buffered saline. [0060] The following examples further illustrate the invention.

EXAMPLES [0061] Cell lines and cell culture: all cell lines were maintained at 37°C and 5% CO2 and ambient oxygen. The following NSCLC cell lines, PC9 (Sigma-Millipore 90071810), NCI-H1975 (ATCC- CLR-5908), HCC827(ATCC -CRL-2868), HCC4006 (ATCC -CRL-2871), NCI-H3255 (Academic source; CCLE Name: NCIH3255_LUNG), and NCI-H1792 (ATCC CRL-5895), were cultured in GIBCO™ RPMI 1640 Medium (1x) (ThermoFisher 11875-093) supplemented with 10% fetal bovine serum (Sigma-Aldrich F2442). HEK293T- LENTI-X™ 293T (TaKaRa 832180) were maintained in GIBCO™ DMEM (ThermoFisher – 10564-011) supplemented with 10% fetal bovine serum. Generation of PC9 persister cells [0062] 2.5x106 PC9 cells plated in a T75 flask were treated with 40nM osimertinib until confluency was achieved. Media and drug were replenished every 4 days. Persister cells in the following assays will be identified with an “R” after the cell name. Drug dose response assays [0063] To establish drug dose response, 2000 cells were plated in each well of a 96 well plate and after 24 hours were treated with increasing amounts of the corresponding drug, at half log increase.96 hours after treatment, cell viability was determined using Promega CELLTITER 96® AQueous One Solution Cell Proliferation Assay (MTS) (G3580) according to manufacturer instructions. IC50 values were determined using GraphPad PRISM™. [0064] The results illustrated in Figure 1 demonstrate that SLC33A1 knockout can sensitize PC9 cells overexpressing some EGFR variants known to confer resistance to osimertinib. The results shown in Figure 2 demonstrate SLC33A1 knockout can re- sensitize PC9 persister cells to osimertinib. The results shown in Figure 3 demonstrate SLC33A1 inhibition activity by osimertinib in cell culture. The results illustrated in Figure 5 demonstrate CsA treatment sensitizes PC9, HCC827, NCI- H1975 or NCI-H3255 cell lines to osimertinib. The results shown in Figure 6 demonstrate CsA treatment re-sensitizes PC9R to osimertinib. The results shown in Figure 7 demonstrate multiple other cyclophilin inhibitors that have similar effect to CsA in re-sensitizing PC9 cells to osimertinib. The results shown in Figure 8 demonstrate sensitizing effect of CsA in PC9/PC9R and NCI-H1975/R. Importantly, these data confirm that the combination of osimertinib and structurally distinct cyclophilin inhibitors can re-sensitize cells that have acquired direct resistance to osimertinib as well as those harboring the T790M mutation relevant for acquired resistance to first- and second-generation EGFR-TKIs (e.g., NCI-H1975). Drug synergy experiments [0065] To establish synergistic effect between osimertinib and CsA, 2000 cells were plated in each well of a clear flat bottom, white 96 well plate and after 24 hours were treated with increasing amounts of the corresponding drugs, at half log increase.96 hours after treatment, cell viability was determined using Promega CELLTITER- GLO® Luminescent Cell Viability assay (G7572). Synergy scores were calculated using the ZIP method [Yadav et el. Comput. Struct. Biotechnol. J., (2015) 13, 504– 513] and using the webtool, synergyfinder plus. The results illustrated in Figure 4 show the synergy between osimertinib and CsA. Crystal Violet Assay [0066] 24 hours before drug treatment, 5000 cells were plated in each well of a 24 well plate in 1 mL of media. Cells were then treated with the corresponding treatment and returned to incubator. After 7-8 days, cells were washed once with 1x PBS and then stained with crystal violet solution: 0.5% w/v crystal violet (Millipore Sigma – C0775) and 20% methanol v/v. [0067] The results illustrated in Figure 8 show the sensitizing effect of CsA in PC9/PC9R and NCI-H1975/R.

Efficacy study of Test Articles osimertinib+CsA or osimertinib+NIM811 compared to single drug treatment in the Treatment of Subcutaneous PC-9 Lung Cancer Xenograft Model in Female Balb/c nude Mice [0068] The assay is to measure the in vivo therapeutic efficacy of the test compound osimertinib, in combination with cyclosporine A or with NIM811, in the treatment of non-tumor bearing female balb/c nude mice and the subcutaneous PC-9 human lung cancer Xenograft model in female balb/c nude mice. PC-9 cells [(CL-00849, P11- 220310) Purchased from: RIKEN BRC CELL BANK; Catalog No. RCB4455; Lot No.003] cancer cells were maintained in vitro with RPMI1640 medium supplemented with 10% fetal bovine serum at 37ºC in an atmosphere of 5% CO₂ in the air. The cells in exponential growth phase will be harvested and quantitated by cell counter before tumor inoculation. Each mouse will be inoculated subcutaneously it the right upper flank region with PC-9 tumor cells (1x 10⁷) in 0.1 ml of PBS mixed with Matrigel (1:1) for tumor development. [0069] When the mean tumor volume reaches approximately 100-200 mm³, animals are randomized by tumor volume and osimertinib and CsA are administered in the formulation 5%DMSO+40%PEG300+5%Tween80+50%ddH2O and NIM811 is administered in the formulation 10%DMSO+40%PEG300+5Tween80+45%saline or 10%DMSO+90%corn oil. 60 mice will be enrolled in the study. All animals will be randomly allocated to 6 study groups, 10 mice in each group. Randomization will be performed based on “Matched distribution” method/ “Stratified” method (STUDYDIRECTOR^TM software, version 3.1.399.19) /randomized block design. The date of randomization will be denoted as day 0. [0070] Animals were monitored daily for morbidity and mortality. During routine monitoring, the animals were examined for any effects of tumor growth and treatments on behavior such as mobility, food and water consumption, body weight gain/loss (Body weights were measured twice per week after randomization), eye/hair matting and any other abnormalities. Tumor volumes were measured twice per week after randomization in two dimensions using a caliper, and the volume is expressed in mm³ using the formula: “V = (L x W x W)/2, where V is tumor volume, L is tumor length (the longest tumor dimension) and W is tumor width (the longest tumor dimension perpendicular to L). Dosing as well as tumor and body weight measurements will be conducted in a Laminar Flow Cabinet. [0071] The results illustrated in Figure 9 show the comparison between single agent osimertinib to the combination of osimertinib with either CsA or NIM811 in-vivo. The combination of osimertinib with either CsA or NIM811 demonstrated greater anti-tumor growth efficacy in the PC-9 Lung Cancer Xenograft Model in Female Balb/c nude Mice, compared to osimertinib alone, CsA alone, or NIM811 alone. CRISPR screen for genes that can modify the activity of CsA [0072] PC9 were transduced to stably express CAS9 under blasticidin (ThermoFisher- A1113903) selection using lentiCas9-Blast (Addgene -52962). Following cell expansion, 288 million cells were resuspended in media containing 1:1000 polybrene (Millipore Sigma -TR-1003) to achieve cell density of 1.5 million cells/ml. Following addition of Brunello library lenti-virus (Broad institute; Doench et al. Nature Biotechnology 34 (2016) 184–191), cells were plated in 12 well plates at 3 million cells/well and then centrifuged at 1000 RCF for 2 hours at 30°C, followed by overnight incubation. The next day, cells were washed once with 1x PBS (ThermoFisher 10010023) and then trypsinized using 0.5ml of 0.25% trypsin (ThermoFisher 25200056). Cells from each two 12 well plates were pooled and replated into three T175 flasks.24 hours after replating, infected cells received 1µg/ml puromycin (ThermoFisher A1113803). After one passage in culture, cells were trypsinized and plated for drug treatment at 14.25 million cells/T175 flask, totaling 2 flasks/replicate, 6 flasks per drug arm (library representation of ~350 cells/sgRNA).24 hours after plating, cells received either DMSO (Millipore Sigma D8418) or cyclosporin A resuspended in DMSO (SelleckChem S2286) at a final concentration of 2.5 µM. Cells were then incubated with the corresponding drug arms for 17 days (media/drug change every 3 days and cell splitting when flasks reached confluence). After 17 days, surviving cells were collected and gDNA was extracted using nucleospin XL blood maxi kit (MACHEREY-NAGEL -740950.50) according to manufacturer instructions. Subsequently, sgRNA sequences were PCR amplified and sequenced using Illumina Hi-seq as described before. After sequencing, PoolQ (described in Hanna et al. Cell 184 (2021) 1064–1080) was used for sgRNA deconvolution and statistical analysis.

Claims

Claims 1. A method for treating non-small cell lung cancer (NSCLC) in a patient in need thereof comprising administering an effective amount of osimertinib, or a pharmaceutically acceptable salt thereof, and an effective amount of a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof. 2. The method of any one of claim 1, 4, or 6, or pharmaceutical composition of claim 7, wherein the cyclophilin inhibitor is cyclosporine A, NIM811, alisporivir, or voclosporin, or a pharmaceutically acceptable salt thereof. 3. The method of claim 2 wherein the cyclophilin inhibitor is cyclosporine A. 4. A method for treating a patient having a KEAP1/NRF2/CUL3 mutant tumor comprising administering an effective amount of a cyclophilin inhibitor or a pharmaceutically acceptable salt thereof. 5. The method of claim 4, which further comprises the administration of an effective amount of osimertinib, or a pharmaceutically acceptable salt thereof. 6. A method for treating non-small cell lung cancer (NSCLC) in a patient having elevated glutathione comprising administering an effective amount of osimertinib or a pharmaceutically acceptable salt thereof, and an effective amount of a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof. 7. A pharmaceutical composition comprising osimertinib, or a pharmaceutically acceptable salt thereof, and a cyclophilin inhibitor, or a pharmaceutically acceptable salt thereof, and one or more pharmaceutically acceptable carriers, diluents, or excipients. 8. A method of sensitizing cancer cells to treatment by an EGFR inhibitor comprising inhibiting SLC33A1. 9. The method of claim 8, wherein the EGFR inhibitor is selected from the group comprising osimertinib, gefitinib, erlotinib, icotinib, afatinib, and dacomitinib. 10. A method of treating non-small cell lung cancer (NSCLC) in a patient in need thereof comprising inhibiting SLC33A1 and administering an effective amount of an EGFR inhibitor, or a pharmaceutically acceptable salt thereof. 11. The method of claim 10, wherein the EGFR inhibitor is selected from the group comprising osimertinib, gefitinib, erlotinib, icotinib, afatinib, and dacomitinib. 12. The method of any of claims 1-12 wherein the patient is human. 17