NZ624881B2 - Administration of nedd8-activating enzyme inhibitor and hypomethylating agent - Google Patents

Abstract

Provided is the use of a combination of a NAE inhibitor, preferably ((1S,2S,4R)-4-(4-((1S)-2,3-dihydro-1H-inden-1-ylamino)-7H-pyrrolo[2,3 d]pyrimidin 7-yl)-2-hydroxycyclopentyl)methyl sulfamate (MLN4924) or {(1S,2S,4R)-4-[(6-{[(1R,2S)-5-chloro-2 methoxy-2,3-dihydro-1H-inden-1-yl]amino}pyrimidin-4-yl)oxy]-2-hydroxycyclopentyl}-methyl sulfamate (I-216), and a hypomethylating agent, preferably azacitidine or decitabine, in the treatment of cancer. )oxy]-2-hydroxycyclopentyl}-methyl sulfamate (I-216), and a hypomethylating agent, preferably azacitidine or decitabine, in the treatment of cancer.

Description

WO 67396 ABMENESTRAWQN Qt; i‘iEBSS—ACTiVATiNG ENZYME ihiifiit AME} HYPQMETHYLATENG AGENT that} This appiicatian ciairns benefit at prierity tram US. Previsianai Patent Appiication hie. 61/555,049 tiied en her 3, 2011. {£992} inhibitien at NEDDSectivating enzyme {MAE} has been shown to induce cancer ceii death and t the grewth at terriers in xenegraft maeeis. See, ea, TA Saucy et at, Nature, with, «$353, ?32~?3?; TA. Seucy et at, (Tim. Cancer Res, 2969, 15 (12}, 3%2—3‘916; and LE. Brewneii et at, Mai. Celt, mm, 3? (1), 1622-1111. Reports at Phase 5 ciinicai studies at an NAE inhibitor inciuee RT. Swerris et at, Bieed, 291i}; 115, With-3809; LS. Keith et at, J. Cite. 0mm, tan, 2Q, abstract 3013; and S. hhatia et at, J. Ciin. anei., 22311, 29, abstract 852%. inhibitors of net are described in U5 i’atent Anni. has. t6fi5ii (Patti. hie. tees/atesasa, Patent hie. ?,951,81t‘i), 11/?OG,514 (Patti. No. 266779191293) end 11/896,338 {Patti No. tees/0051404, patent he. 8,008,307), each of the aierementioneri eahiicatiens is herehy inceraerateri by reference herein in its entirety. it there is any ciiscrenancy between any at these dacurnents and the eresent sneeiticatien, the present saeciiicatian centreis, 3383} i-iyeomethyiating agents have been apprnveci by the US Feed anti Drug Administration in the treatment (if cancer. Fer examnie, VEBAZAQ’ iazaciticiine tar injectien) is indicated fer treatment at patients with the teiiewing French-American—hritish {FAB} myeieeysniastic synaremes subtypes: refractory anemia {RA} er retractery anemia with ringed siderehiasts (it accempaniee by neutroeenia er ecyteaenia er requiring usiens), reiractery anemia with excess hiasts {RAEB}, refractery anemia with excess hiasts in transierrnatien iRAEB-Ti, anti chrenic myeiemenecytic ieukemia {Chen/tat).

DASQGEN® (ciecitabine for iniectien} is indicated for treatment at ts with myeiedyspiastic syndremes (MQ5) inciiiciing nrevieasiy treatea and untreated, rte have and secondary M65 of aii French American~8ritish subtypes (refractory , refractory anemia with ringed sitierehiasts, refractory anemia with excess hiasts, tory anemia with excess hiasts in ermatien, anti ic myeiemenocytic ieukerniai anti intermediate-1, intermediate—2, and high-risk internationai Prognostic Scaring §ystem greens. {tree} The highest nessihie chase (MTD: maximum teierateci rinse} is typicaiiy sought for agents fer the treatment of cancer because the benefit of the treatment is heiieveci ta increase with rinse. See, eg, Y. tin and WJ. Shih, Biestntistics, earn, 2 (23, 5. A synergistic natien at agentswthat is, a combination of agents that is more ive than is expected from the effectiveness of its tuents, without also compounding the treatment side effects—can provide an opportunity to r even greater efficacy at the MTD. Accordingly, it can be desirable to discover synergistic combinations of anti-cancer agents in order to treat cancer patients most effectively, without overloading the patient with side effects.

It has now been discovered that the administration of an NAE inhibitor or a pharmaceutically acceptable salt f and a hypomethylating agent or a pharmaceutically able salt thereof provides a synergistic . Both in vitro and in vivo synergistic effects were found. In vitro synergy was ed using The Combination Index (M.C. aum, J. Theor. Biol., 1985, 114, 413-431), as discussed in further detail below. In vivo synergy was measured according to a y survival method or a synergy tumor growth method, as discussed in further detail below.

At least one aspect of the present disclosure relates to methods of treating cancer comprising administering to a patient in need of such treatment, a therapeutically effective total amount of an NAE inhibitor or a pharmaceutically acceptable salt thereof and a hypomethylating agent or a pharmaceutically acceptable salt thereof.

At least one aspect of the t disclosure is also directed towards the use of an NAE inhibitor or a pharmaceutically acceptable salt thereof with a hypomethylating agent or a pharmaceutically acceptable salt thereof for treating cancer in a patient in need of such treatment.

At least one aspect of the present disclosure relates to a kit comprising at least one medicament for use in treating cancer in a subject in recognized need thereof. For example, the kit may comprise at least one medicament comprising at least one dose of an NAE tor or a pharmaceutically acceptable salt thereof, and ctions for administering the at least one medicament with a hypomethylating agent or a pharmaceutically acceptable salt thereof; or the kit may comprise at least one medicament comprising at least one dose of a hypomethylating agent or a pharmaceutically acceptable salt thereof, and instructions for administering the medicament with an NAE tor or a pharmaceutically acceptable salt thereof. In various embodiments, the kit can se at least one medicament comprising at least one dose of an NAE inhibitor or a pharmaceutically acceptable salt thereof and at least one medicament comprising at least one dose of a hypomethylating agent or a pharmaceutically acceptable salt thereof, and instructions for administering the medicaments. Furthermore, for example, the kit can comprise anti-cancer actives consisting of at least one medicament comprising at least one dose of an NAE inhibitor or a pharmaceutically acceptable salt thereof, and at least one medicament comprising at least one dose of a hypomethylating agent or a pharmaceutically acceptable salt thereof; said kit for ng cancer further comprising dosing instructions for administering the medicaments for treatment of the t in recognized need thereof.

At least one aspect of the present disclosure relates to at least one medicament for use in treating cancer in a subject in need of such treatment. For example, the at least one medicament may comprise an NAE inhibitor or a pharmaceutically able salt thereof, or a hypomethylating agent or a pharmaceutically acceptable salt thereof, or a combination thereof.

At least one aspect of the present disclosure relates to the use of an NAE inhibitor or a ceutically able salt thereof in the manufacture of a ment for treating cancer, said treating comprising administering the NAE inhibitor or a pharmaceutically acceptable salt thereof in ation with a hypomethylating agent or a ceutically acceptable salt thereof.

At least one aspect of the present disclosure relates to the use of a hypomethylating agent or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for treating cancer, said treating comprising administering the a hypomethylating agent or a pharmaceutically acceptable salt thereof in combination with an NAE inhibitor or a pharmaceutically acceptable salt f. [0011a] At least one aspect of the present disclosure relates to the use of an NAE inhibitor or a ceutically acceptable salt thereof, and a hypomethylating agent or a pharmaceutically acceptable salt thereof, in the manufacture of a medicament for treating cancer.

BRIEF DESCRIPTION OF THE S shows the Combination Index values for NAE inhibitors MLN4924 and I-216, each separately in combination with azacitidine or decitabine in HL60, OCIM2, NB4 and THP-1 cell lines. shows a plot of tumor volume as a function of time in an HL-60 subcutaneous xenograft model ing subcutaneous treatment with: the vehicle alone, MLN4924 as a single agent, azacitidine ("Aza") as a single agent, and inistration (s.c.) of MLN4924 and azacitidine, on Days 1, 4, 8, 11, 15 and 18 at the indicated doses. shows a plot of tumor volume as a function of time in a THP-1 subcutaneous xenograft model following subcutaneous treatment with: the vehicle alone, MLN4924 as a single agent, azacitidine ("A23“) as a singie agent, and nistratten {SAL} tn“ 4 and azacétidtne; on Days 1, 4, 8, 11, 15 and 18 at the indicated deses.

E615} Fifi. 4 shows a ptat Qt turner veiume as a function of time in a CECE-ME subcutaneous xemgraft modei toiiewing subcutaneeus treatment wéth: the e akme, MtNltS-‘azzl as a singie agent, azecitidine ) as a singte agent, and ca—administration €590} 03‘ MLNAQZQ and azacitédtne, cm Days 1, 4, 8; 11, 15 and 18 at the émfiicated desesn {ms} HS 5 shews a met 0? percentage suwivai as a function of time in are Htfifi inated motiei tgiiewing subcutaneeus treatment with: the vehicée aime, MtNttQZi-i as a single agent, azecitidine {"AzaC“) as a singie agent; and ce—administratien {st} :3? MLN4§24 and azacitédine cm Days 22, 25, 2g, 32, 35, 39 at the intimated doses. {31?} The feiiowing definitécns and abbreviations may be used : ALP aikafiine ghosphatese ALT aianine ammotransferase Aft/it acute myeicgenaus Seukemia ANC absatute neutmphii count AST aspartate aminotransferase AUC area under the piasma concentratém versus time curve SSA body surface area CR campiete respense CRM continuat reassessment method CYP cytcchrome $1450 DLECL diffuse tatge B~ceii Eymphoma [3LT dose—Eimitmg toxicity 2012/063382 tFT iiver en tests LVEF ieft veetricuier ejectien freetien MQS myeiodyseiastie syndromes iviivi muitipie myeiema MTD maximum teiereted dese NAE ectiveting enzyme NEDDtB heurai ereeurser eeii expressed, deveiepmentaiiy dewn~reguieted 8 PAS? huimehery artery systeiic re Pit partiai reaeehse {1E} once deity SCLC smaii ceii iung center {6318} As deed herein, "dese'iimiting toxicity" (BLT) is defined 33 a negative event eensidered by the administering ehysieian t0 he reiated ti) therapy with MtNtigzii such that the administering physician heiieves the deses Sheuid he iimited in quantity er eitegether stepped. ee at such evente inciude: & Grade 4 neutrepenia (ANC < 500 eeiisfmm3) Betting mere than "i censecutive days a Grade 3 neutrepenie with fever and/’er infectieri, where fever is defined as an erai temperature a 38.5% 8 Grade d thremheeytepenia (pieteiets < 25,90fl/mm3 but > /mm3) iaeting more than I? eeneecutiye days a Grade 3 thremhecyteeenie with hieeding e A pieteiet eeunt <: 10,533/mm3 at anytime a Grade 3 er greetei’ haueea anti/or emesis despite the use at optimai antiemetic prephyiaxis (wherein “eetimei antiemetie preehyiaxis" is defined as an anthemetie n that emeieys a 2012/063382 54ft} antagdnist given in standard ddses and accprding ta standard scheduiesi. Dexamethasene sheuid net be used because (if its {WEAninducing s. it tirade 3 or greater diarrhea that pccurs despite maximai suppdrtive therapy a An ahsoiute reduction in tVtEf- of a 18% te a vaiue < 59% tag, LVEF = 133% in a patient with LVEF = 55%. at baseiinei e A decrease in LVEF te <: 40% a An increase in PAS? tn :> St) mm Hg er 3 x haseiine 9 Any ether firade 3 er greater nanhematningic texicitv with the feiinwing exceptiens: 0 Grade 3 arthraigiairnyaigia 0 Brief (< 1 week) Grade 3 fatigue 0 Grade 3 fever that occurs in the ahsence pf Grade 3 er worse neutreeenia er decurnented infection faiinwing daiiv administratinn of intranets a Treatment deiay of mere than 1 week because at a tacit of adequate receverv at MtNdQZd» reiated hemateipgicai pr nenhentatoidgic toxicities is ztiweiated texicity that requires that any ddses nf i’vititi4924 are missed during a cycie pr discentinuatinn of therapy with tvithinli {€319} As used herein, "ciinicaiiv effective arndunt” anti “therapeuticaiiv effective” means an ameunt at a therapeutic substance that is sufficient upen apprepriate administration ever an apprepriate peried at time td a t (a) ti) cause a detectabie decrease in the severitti at the diserder er disease state being treated; (b) tn nrate or aiieviate the patient's svrnptnrns ef the disease er diserder; or (c) tn sinvv er prevent advancement at, or athervvise stabiiize er prnieng stahiiizatinn at, the disprder er disease state being treated (for instance, tn t additianai turner grewth or inhibit the ceii growth pi a ).

Edith} When mere than ene therapeutic suhstance is being administered, the "ciinicaiiv effective totai ” er “therapeuticaiiy ive tetai arneunt” means that the sum at the individuai amounts of each therapeutic substance meets the tion of “ciinicaiiy effective arndunt” even if the individuai ampunts at any nurnber ef the individuai therapeutic suhstances weuid net, fer exampie, if 10 mg of A were net a ciinicaiiv ive arneunt, and 20 mg 0f 8 were net a aiiv effective amdunt, but the administratipn (if 10 mg A + 2% mg 3 resuited in at ieast ene of the resuits enumerated fer the definitien 0f ”ciiniceiiy effective amnent,“ then the sum ef 19 mg A + 2%) mg 8 weuid be censidered a “ciinieeiiy effective zeta! eminent.” {£321} in any,i ferrn or cemeesitien, the sifiered deseis} er the eiiy effeetive (tetai) amennt can be expressed as emountisi of therapeutic substanceie} per t BSA, ega, as mg/mz. {£922} As used herein, "patient” means a human being diegnesed with, exhibiting symptems 0? or ntherwise beiieved in he afflicted with a e, er er cenditien and thee in recegnized need ef the treatmenit deeeribed . {@233 As need herein, the iiiuetreiive terms "meme,” “eueh ae,“ ”fer exempie” and the iike {and variations thereef, H e.g., ”inciudes" and H‘ineiuding, i! exempies“), uniess otherwise specified, are intended to he neneiimi‘iing. That is, uniees exeiicitiy eteted etherwise, such terms are intended to imeiy ”but net iimited tn," eg, "inciuding" means inciuding but not Eimited tea {832%} As used herein, ”bedy surface area" (BSA) is eeicuieted wine a standard am, e.g., Ht (emEX Wtikg) Ht (mix~ Wt 5 $33 3 BSA (mg) a nr SgA : 3503 3133.

Therapeutic Sebeteneesmi‘eAE inhihitere. {6325} The cemenund i(15,2§,4R)«4~(4«((153~23~dihydmw1H-inden-1—yiamine)~7H-eyrreie{2,343} eyrimidino?nyiin2-hydrnxyeyeiepentyiimetnyi euifameie: MLN4§24 Hzixi’ ‘0 OH eise knnwn as MLNAQM. has been reported in he an inhibiter ef NEfiasveetiveting enzyme {NAE}. See, eg.; TA, Sidney et mi, Nature, enee, 458, 732337; TA: Snucy et aL, Ciin. Cancer Ree, 263%, 15 (12), 3§12n3§16; and LE. Brnwneii et ai, Mei. (fed, mm, 3? (1}, 102~111. As discussed abeve, MLNdQZd, pharmaceutieafiiy aeeeptabie seits thereef, pharmaceuticei tempeeétéens 0f MLN4924 or a pharmaceutéceiiy aeeeptebie eait thereof, preeeeses fer synthesis, and peéymerphic ferme thereof have been deeeréeed previeusiy. See, e.g., US Patent Appi. Neg. 1.1.;me,e:4 (Pubi. Ne. zeeyeielzeg), ,3‘39 (Pubi. N0. 2009I00366?8) and ESE/WEBB: (Pam. Ne. Zfllllflflmfidd). MLN4§Z4 Brug Substance ze—es“; is the hydrechieride sai‘r 0f MLNIESZQ, 5e, é{13,23,11%)4444{lS}*2,3-dénydrd- 1Hwinden~1~yiemine}*?H~pyrreie{2,3ed}eyrérnidin»?—yi)w2-nydrdxycyciepentyfimethyi ate hydreehieréde. {8&ng The cempdund §,4R3-4~{firm1R,2§§--5«cniorenz-methexy-Zfi-dihydm—lH-inden»1» yiiamino}pyrimid§n~4ny§mxy§~2nhydrexycyciepeniyiMethyi suifamete: 54216 (3 N1“?! H N‘- MM 2 E’s-‘0 O n aim knewn as 5—215, has aise been reported :0 be en inhéeiier ef NAE. See US Patent Appiication Neg 13f592,389, flied August 23, 2012, eieéming erierity te US Previeieneé Patent A9333. Ne. 512325336, fried August 24, 2011, which are hereby incorporated by reference herein in their entirety. if there is any discrepancy between theee documents and the preeent speeifieetéen, the present speeéfication centreis.

Thereeeutie Sebstenceemfiyeemetnyietirag Agemsc WE'RE idine is 4~amine~1—B~Derieefuran05y5~5~triazin~2(1H}»ene {EUPAC name: e-aménenl-fi—D— r6idemranesyielfifieriezinfi(1H3~dne): H0 N O 0H OH WO 67396 2012/063382 As discussed aheve, VEQAZA‘” (azacitidine fer idn, Ceigene Coreoration (summit, Ni); ViDAZAt" is a registered trademark: ef Ceigene Cerpnratieni is indicated and anpraved by the US FQA for treatment at patients with the idiiowing French~American~British (FAB) myeiedyseiastic syndromes subtyees: refractery anemia (RA) er refractdry anemia with ringed siderditiasts (if accompanied by neutronenia er tnrnmedcytdnenia er requiring transfusidns), refractory anemia with excess biasts , retracted,i anemia with excess hiasts in transtdrmatien (RAE-:33}, and chrnnic myeidmonocytic ienkemia (CMMGL).

Fuii prescribing atidn fer ‘E’ is hie in the Cdmmerciai package insert. {@283 Decitahine is 4emine~1~(2~deexy-dflerythrdnentefuranesyi}*1,3,5~triazin~2{1H3-ene: n \n no N (I) {dig} DACOGEN® {decitabine for iniectien, Eisai, inc, Weddciitt take, N3; QACOGEN® is a registered trademark (if Edeerfien, inc., Duhiin, CA) is indicated and apprnved try the US Film fer treatment of ts with myeindysniastic syndremes (Mild) ing nrevidnsiy treated and untreated, de new and secondary MES (it aii trench-American-British es {refractdry anemia, refractnry anemia with ringed siderehiasts, refractdry anemia with excess niasts, refractory anemia with excess hiasts in transfnrmatidn, and chrehic myeiemendcytic ieuiterniai and intermediatevt, intermediatenz, and high- risk internatienai prognestic Scaring System groans. Fdii prescribing infarmatien fer DACQGEW is avaiianie in the commerciai package insert, Cempddnd Administratinn Kidd} it has new been discovered that the administration at an NAE inhibiter or a eeuticaiiy accedtahte sait thereef and a hypemethyiating agent or a nharmacenticatiy acceptante sait thereef can previde a synergistic effect, {$313 The NAE inhibiter er a pitarrnacetititaiiyi eccentahie sait thereef iNAEi) can he administered in cdmhinatidn with the hynemethyiating agent or a nharmaceuticaiiy acceptabie sait therenf (HMA) in a singie ddsage term or as a separate ddsage term. When administered as a separate dosage term, the hypemethyiating agent er a eharmaceuticaiiy anie sait theredf can be administered prior to, at the same time as, er fniiewing stration at the NAE inhibiter or a pharmaceuticaiiy acceptabie sait thereof, As used herein, the administration in "combination" ei‘ NAEE and HMA refers not eniy te simuitaneous dr sequentiai stratien (it the two agents, but aise tn the administration of bath nds during a singie treatment cycie, as understodd by ene skiiied in the art. {$32} in seme embediments, the present sdre s te treating cancer in a patient by administering tn the patient an NAE inhibitnr er a nharmaceuticaiiy accentahie sait thereef (NAB) and a hypemethyiating agent er a pharmaceuticaiiy ahie sait therent {HMA} aecnrding tn a Zdvday cycie as idiiews: administer NAEi on Days 1, 4, S and 11; and administer HMA en Days 1, 2, 3, ti, 5, 8 and gt Optinnaiiy, the first cycie is 33 days with administratien at NAEi en Bays 1, 4, 13., and 15 and administratien of HMA en [Bays 8, 9, 10, 11, 12, 15 and 3.6, with subsequent cycies di 28 days as described in the ing sentence. £033} in same embodiments, the present diseiesure reiates tn treating cancer in a patient by administering to the patient an NAE inhihitor er a pharmaceuticaiiy acceptahie sait theredt iNAEii and a hynemethyiating agent er a pharmaceuticaiiy abie sait thereof iiniiViA} aecerding to a muddy cycie as idiiews: administer NAEi en Days 1, 3, and S; and administer Hit/in an Days 1, 2, 3, ii, 5, 8 and 9.

Gptienaiiy, the first cycie is 35 days with administration at NAEi on Says It, 3, and E3 and administratien at Hit/3A en days 8, 9, 1t), 11, 12, 15 and 18, with subsequent cycies of 28 days as described in the preceding sentence.

E9343 in varinus embndiments, the NAEi may be {i13,23,4Ri-d-(«Hi15}~2,3—dihydre-1H-inden~1~ yiarnino)~?H-nyrrdini2,3~d}pyrimidin-‘iryiinzwhydrexycycieeentyiimethyi suitamate es“) or {i13,25,4R)-ti~{ifri{i1R,2$)«5-cninrn~2nmethexy~z3-dihydrenli-i-inden-inviteminefipyrimidin~d~yiioxyi~2~ hydrexycyeiepentyiimethyi sniiamate {”i~216"}. in at ieast tine embodiment, the NAEi is Mti‘idgzzi. in at ieast one embodiment, the NAEi is i-216.

Edfifii in varinns emhediments, the men may he azacitidine er deeitahine, in at ieast tine emhndiment, the HMA is azacitidine. in at ieast dne embodiment, the HMA is deeitabine. {ass} in varieds embodiments, MtNdQZd is administered in cemhinatian with azacitidine. in various emhediments, Nitrite-92d is administered in atien with decitahine. in varieus emhediments, infild is administered in cemhinatinn with azacitidine. in varieties ments, i-Zlfi is administered in eembinatien with decitabine. {93?} in varidus ments, the NAEi is administered at a dnse of about 20 nag/ma, 3t) ml, 49mgjrn2, 45 mgjmz, 5t) l, dieing/m2 er 75mgjmz. in variens embodiments, the HMA is administered at a dose of about 3’5 mg/‘rnz. {ass} in various embediments, the NAEi is stered enousiy. in various embddiments, the NAEi is stered oraiiy. in varieds embediments, the NAEi is administered subcutaneousiy. in varinus embodiments, the HMA is administered intraveneusiy or subcutaneeosiy. {33%} in some embodiments, the present disciosure reiates tn treating cancer in a patient by administering tn the patient an NAEi and a hypomethyiating agent HMA accerding to a 28~day cycie as ioiiows: administer the NAEi an Says 1, 4, 8 and 11; and administer HMA an days 1, 2, 3, 4, S, 8 and Si; wherein the NAEi is Mti‘tégm and i-iiViA is azacitidine; n masses is administered intravenousiy at a ddse of about 20 mgjrnz, 30 mglrnz, lifting/m2, 45 nag/ml, fiflrngirnz or 7’5 mg/mz; wherein idine is administered at a dose at abdnt 75 mgjrnz; and wherein the cancer is a hematoiogic maiignancy. in varieus embodiments, the nematniogic maiignanrzyi is acute myeidid ieekemia (AML) or ysniastie syndromes (M33), in various embodiments, the hematoiogic maiignancy is AML. in various embodiments, the hematoidgic maiignancy is Mitts, Eddtii in some embediments, the present disciosdre reiates tn treating cancer in a patient by administering to the patient an NAEi and a byeomethyiating agent HMA accerding to a 28~day eyeie as tniiows: administer the NAEi on Days 1, 3, and 5; and ster HMA en Bays 3., 2, 3, Ii, 5, S and 9; wherein the NAEi is d and HMA is azacitidine; wherein Mtngzd is administered intravenousiy at a dose of about 20 mg/mz, 3i) mgimz, edmgfmz, 45 mg/m2, St) neg/mg, tittirnglm2 or 7’5 mgimz; wherein azacitidine is administered at a dose of street "i5 mg/rnz; and wherein the cancer is a hemateiogic maiignancy, in varieus embodiments, the hematoiogic maiignanmi is acute d ieuitemia {An/it} or myeindyseiastic syndremes {Mitts}. in various embodiments, the hematoidgic maiignancy is AML. in s embodiments, the bemateiogic maiignancy is MDS. edtie dubstanee; dharmacedticai Comeesitiensi {this} The theraneutic substance can be a nharmaceuticaiiy acceptabie saitx in same embndiments, such saits are derived from innrganic er nrganic acids or bases. For reviews of snitabie saits, see, an, Serge et at, in Pharm. Sci, td‘i’Z 66, 3.49 and Remington: The Science and Practice of Pharmacy, 20th Edi, A. Gennard (ed), tinpincott Wiiiiams 84, Wiiirins (2600): Examples of suitable acid on salts include acetate, adipate, alginate, aspartate, benzoate, e sulfonate, bisulfate, butyrate, citrate, camphorate, camphor sulfonate, cyclopentanepropionate, digluconate, dodecylsulfate, ethanesulfonate, fumarate, glucoheptanoate, glycerophosphate, hemisulfate, heptanoate, hexanoate, hydrochloride, hydrobromide, hydroiodide, 2-hydroxyethanesulfonate, lactate, maleate, methanesulfonate, 2-naphthalenesulfonate, nicotinate, oxalate, e, pectinate, persulfate, 3-phenyl-propionate, picrate, pivalate, propionate, succinate, tartrate, anate, tosylate and undecanoate.

Examples of suitable base addition salts include ammonium salts; alkali metal salts, such as sodium and potassium salts; alkaline earth metal salts, such as calcium and magnesium salts; salts with organic bases, such as dicyclohexylamine salts, N-methyl-D-glucamine; and salts with amino acids such as arginine, lysine, and the like.

For example, Berge lists the following FDA-approved commercially marketed salts: anions acetate, te (benzenesulfonate), benzoate, bicarbonate, bitartrate, bromide, calcium edetate (ethylenediaminetetraacetate), camsylate (camphorsulfo nate), carbonate, chloride, citrate, dihydrochloride, edetate (ethylenediaminetetraacetate), edisylate (1,2-ethanedisulfonate), estolate (lauryl sulfate), esylate (ethanesulfonate), fumarate, gluceptate (glucoheptonate), ate, glutamate, glycollylarsanilate (glycollamidophenylarsonate), esorcinate, hydrabamine (N,N'-di(dehydroabietyl)ethylenediamine), hydrobromide, hydrochloride, hydroxynaphthoate, iodide, isethionate (2-hydroxyethanesulfonate), lactate, lactobionate, malate, maleate, mandelate, mesylate (methanesulfonate), methylbromide, nitrate, methylsulfate, mucate, napsylate (2- naphthalenesulfonate), nitrate, pamoate (embonate), pantothenate, phosphate/diphosphate, polygalacturonate, salicylate, stearate, tate, succinate, sulfate, tannate, tartrate, te (8- chlorotheophyllinate) and triethiodide; organic s benzathine (N,N'-dibenzylethylenediamine), chloroprocaine, choline, nolamine, ethylenediamine, ine (N-methylglucamine) and procaine; and metallic cations aluminum, calcium, m, magnesium, potassium, sodium and zinc.

Berge additionally lists the following A-approved cially marketed (outside the United States) salts: anions adipate, alginate, aminosalicylate, anhydromethylenecitrate, arecoline, aspartate, ate, butylbromide, camphorate, digluconate, dihydrobromide, inate, glycerophosphate, hemisulfate, hydrofluoride, hydroiodide, methylenebis(salicylate), napadisylate (1,5-naphthalenedisulfonate), oxalate, pectinate, persulfate, phenylethylbarbiturate, picrate, eroeionate, thiocyanate, tosyiate and undecanoate; _ organic cations henethamine {hi-henzyiphenethyiamine), zoie {tun—chiorohenzyhzneyrroiiidinert“'yimethyihenzimidazoiei, diethyiarnine, eioerazine and tharnine {trisihydroxymethyiEarninomethane); and rnetaiiic cations barium and bismuth. toss} As used herein, "oharrnaceuticaiiy acceptahie carrier" refers to a ai that is compatihie with a recipient subject {a mammai, for instance a human) and is suitahie for deiiverine> an active agent to the target site without ating the activity of the agent, The toxicity or adverse effects, if any, associated with the carrier are, for exameie, commensurate with a ahie risk/benefit ratio for the intended use at the active agent. {@4133 The pharmaceuticai itions for use in the s of the present disciosure can be manufactured hy methods such as conventionai granuiating, mixing, dissoiving, encapsuiating, iyoehiiizing, or emuisitying processes, among others. Compositions can he produced in various forms, inciuding granuies, precipitates, or particuiates, powders, ing freeze dried, rotary dried or spray dried powders, amorphous powders, tahiets, cansuies, syrup, suppositories, injections, ernuisions, eiixirs, suspensions or seiutions~ Forrnuiations can contain stahiiizers, hit modifiers, surfactants, seiuhiiizing agents, hioavaiiahiiity modifiers and combinations of these, toast itharrnaceuticaiiy accehtahie carriers that can he used in these compositions inciude ion exchangers, aiumina, aiurninum stearate, iecithin, serum ns, such as human serum aihumin, buffer substances such as phosphates or carbonates, giycine, sorhic acid, potassium sorhate, nartiai giyceride mixtures of saturated vegetahie fatty acids, water, saits or eiectroiytes, such as nrotarnine suitate, disodium hydrogen phosphate, potassium hydrogen ohosnhate, sodium chioride, zinc saits, coiioidai siiica, magnesium trisiiicate, ooiyvinyi nyrroiidone, ceiiuiose—hased substances, ooiyethyiene giycoi, sodium carhoxymethyiceiiuiose, wiates, waxes, noiyethyiene~ooiyoxyorooyienehiock noiymers, poiyethyiene giycoi and wooi tat. tees} These pharmaceuticai compositions are tormuiated for pharmaceuticai administration to a mammai, such as a human beings Such compositions can he administered oraiiy, oarenteraiiy, hy tion spray, tonicaiiy, iy, hasaiiy, huccaiiy, vaginaiiy, or via an imeianted reservoir. The term terai” as used herein es aneous, intravenous, intraneritoneai, intramuscuiar, intra~articuiar, synoviai, intrasternai, intrathecai, intraheeatic, intraiesionai and intracraniai injection or infusion techniques. in some emhodiments‘, the compositions are administered oraiiy, intraveneusiy, er aneeusiy. in some emhndiments, the campesitiens are stered eraiiy. in some emhndirnents, the cumpesitions are administered intravenuusiy. these tnrmuiatiens can he designed tn he shert~acting, tastnreieasing, er impacting . Furthermore, the cempasitidns can he administered in a iocai rather than systemic means, such as adrninistratiun (an; by iniectiun) at a turner site. {use} hharmaceuticai fermuiatiens can he prepared as iiquid suspensidns er sdiutiens using a iiduid, such as an dii, water, an aicehei, and cemhinatiuns (if these. Soiuhiiizing agents such as cyciedextrins can he ed. Pharmaceuticaiiy suitahie surfactants, suspending agents, er ernuisitying , can he added fer erai er parenterai administratiun. Suspensions can inciude oiis, such as peanut nii, sesame eii, seed eii, cern (iii and eiiye aii. Suspensien preparations can aisu contain esters at fatty acids such as ethyi eieate, iseprepyi myristate, fatty acid giycerides and acetyiated fatty acid giycerides.

Suspensien tnrrnuiatiens can inciude aiceheis, such as ethanui, isdprdpyi aicohoi, hexadecyi aicuhei, giycerei and prnpyiene giycei; ethers, such as peiyiethyienegiycei}; petroieurn hydrocarbons such as minerai (iii and petreiatum; and water. {dds} Steriie iniectahie terms at these pharmaceuticai cempositiens can he aduenus er eieagineus suspensiuns. These suspensions can he formuiated accerding te techniques knewn in the art using suitahie dispersing er wetting agents and suspending agents. The steriie iniectahie preparation can aise he a steriie injectahie sdiution er suspension in a nen-texic parenteraiiy acceptahie diiuent er t, for exampie as a seiutidn in l,3~hutanedidi, Ameng the iiiustrative yehicies and soiyents that can he empiayed are water, Ringer’s on and isotonic sedium chieride seiution. in additinn, steriie; fixed diis are tiunaiiy empidyed as a sdivent er ding medium. For this purpese, any hiand fixed eii can he empieyed ing synthetic mono~ or di~giycerides Fatty acids, such as nieic acid and its giyceride derivatives are usefui in the preparation of injectahies, as are i pharmaceuticaiiy» acceptahie eiis, such as eiive dii er caster uii, for instance in their yethyiated ns. "these dii sdiutions or suspensidns can aise contain a idngvchain aicnhni t er dispersant, such as carhexymethyi ceiiuiese or sirniiar dispersing agents which are cemmeniy used in the tormuiatien at pharmaceuticaiiy acceptahie ddsage terms inciuding emuisiuns and suspensinns. Other cemmeniy used surfactants, such as Tweens, spans and ether emuisifying agents ur iiahiiity enhancers which are cnrnrncniy used in the cture at pharmaceuticaiiy acceptahie seiid, iiduid, er ether dusage terms can aise he used fer the purposes of forrnuiation. Cernpnunds can he terminated fer parenterai administratien ey injectien such as by eoies injectien or centinueus on. A unit desage term fer injectien can he in amneeies er in rnuitindese centainers. {i352} Fer exampie, in varieus embediments er“ the present diseiesere, the NAEi is MtNddZd injectien Drug precinct QSiZd-EBP“). MtNdQZQdDP is termeiatee with the feiiewing excieients: citric acid; sediern hydrexide; Cyciedextrin Seifehetyiethers, Sediern $aits (Captisei‘sig and water fer injection. in at ieast ene embedirnent, MLNd§29»iB? censists et 10 rng/rni. MLNdQZd {as free hasei in a seiutien centaining 50 mm citrate heifer and 100 mgjmi. seifehetyiether Bicyciedextrin, pH 3.3. tesat MthigZdniBP has experienced stahiiity erehieins when diieted in saiine. MtNdQZd-EDP can he used fer the duration of the retest eeried indicated on the Certificate of Anaiysis. in erastice, MLNdQZdniDP has heen stared refrigerated at 5°C i 3°C. Each Tyne i giass viai neminaiiy centains 5 mt ei commended e ion, seated with a Tefienii-ceated eetyi rubber r and everseaied with an aiurninurn seai with a piastie the—0hm9 can. {£334} in s embedirnents ef the present disciesere, the HMA is azaeitidine. idine is cemmerciaiiy avaiiahie VEBAZA® {azacitidine fer injectieni, which is sueeiied as iyephiiized eewder in ESQ-mg singie~nse viais. Refer te the VEDAZA a package insert fer additienei intermatien. {@553 These eharmaeeuticai cemeesitiens can he eraiiy administered in any oraiiy acceetahie dosage term ineieeing caeseies, tahiets, aeueeus seseensiens er seititions. When aeeeees seseensiens are required fer erai use, the active ient Can he eemhined with emeisitying and suspending agents. if desired, certain sweetening, havering er eeiering agents can aiso he added. Fer erai administration in a caeseie term, esefei diiuents inciude iattese and dried cornstarch: in the case at taiiiets for orai use, carriers that are eemmeniy used inciede iactese and tern starch, ating , such as magnesium te, are aise tyeicaiiy added. Ceatings mayi he used fer a variety ei eereeses, e.g., to mask taste, te affect the site ef disseiution er ahserption, or te nreiong drug actien. Ceatings can he anniied he a tahiet or te graneiated eartieies fer use in a capseie. {add} ativeiy, these nharmaceeticai eemeesitiens ear: be administered in the term ei’ seenesiteries fer rectei administratien. These can he ereeared by mixing the agent with a seitahie nen~irritating exeieient which is seiid at reem temperature but iieeid at reetai temperature and therefore wiii meit in the reeturn te e the drug. Such materiais intieee tecea butter, beeswax and hyiene giyceis. 2012/063382 tear} These pharmaceuticai cameesitiahs can aisa he administered toeicaiiy, for instance when the target at treatment es areas or ergans readiiy accessihie hy teeicai appiicatien, inciuding es at the eye, the skin, er the iewer intestinai tract. Suitahie teeicai fermuiatiens are readiiy prepared for each at these areas er argahs. teas} Tepicai atieh fer the iewer intestinai tract may be effected in a rectai suppesitery fermuiatien (see abevei er in a ie enema iarmuiatieh. Tepicaiiytransdermai hatches can aise he used. For topicai atiens, the pharmaceuticai campesitiens can he fermuiated in a suitahie eintment containing the active cemeeneht suspended at disseived in one at mere carriers. Carriers fer topicai administratien at the cemeeunds (if the present disciesure inciude i eii, iiduid aturn, white eetreiatum, prppyiehe giycei, eeiydxyethviene, peivexvprepyiene cemeeund, emuisitying was and water. Aiternativeiy, the pharmaceuticai cempesitiens can he fermuiated in a suitahie ietien er cream containing the active cempenentis) suspended or disseived in at ieast ene pharmaceuticaiiy acceptahie carrier“ Suitahie carriers inciude minerai eii, serbitan menestearate, peiyserhate 6i), cetyi esters wax, cetearyi aicehei, Z—ectyidedecanei, henzyi i and water. {ass} Fer ephthaimic use, the pharmaceuticai cemeesitiehs can he fermuiated as ized suspensiehs in isetenic, tit-i adjusted steriie saiihe, er, for instance, as seiutiens in isetenic, pi-i adjusted steriie saiine, either with our without a vative such as henzyiaikenium chioride. Aiternativeiy, fer imic uses, the pharmaceuticai cempesitiens can he fermuiated in an eintment such as petrpiatum. fitted} The pharmaceuticai cemeesitions can aise he stered by nasai aerasei er inhaiatieh. Such cameesitiens can he prepared accerding ta ques known in the art at pharmaceuticai termuiatien and can he prepared as seiutidhs in saiine, emeieying hehzyi aicohei pr ether ie preservatives, absorptien eremeters ta enhance hieavaiiahiiity, tiuerecarhehs, and/er ether cenvehtienai seiuhiiizihg er dispersing agents. {hat} The metheds disciesed herein can he used ta treat diseases, diserders, and cenditiens in which inhibitien at MAE enzyme activity is detrimentai ta survivai and/er expansion ef diseased ceiis or tissue (ea, ceiis are sensitive to NAE inhihitien; tien of NAE activity disrupts disease mechanisms; reductien at NAE activity stahiiizes protein which are inhihiters of disease mechanisms; reductien at NAE activity resuits in inhihitien of ns which are aetivatprs uf disease mechanisms). The diseases, disorders and conditions can aiso e those which reouire effective cuiiin and/'or uhiouitination activity, which activity can he reguiated by diminishing NAE enzyme ty. toast For exampie, the methods disciosed herein can he usefui in treatment of disorders invoiying ceiiuiar proiii‘eration, inciuding disorders which require an effective cuiiin—deoendent uhiquitination and proteoiysis pathway (the, the uhiduitin proteasome yi for maintenance andfor progression of the disease state. The methods of the oresent disciosure can he useiui in treatment of disorders WAF/CiPl mediated via proteins (ea, NF‘KE activation, effigy activation, p21 activation, p53 tion} which are reguiated hy MAE activity. Representative disorders inciude proiiieratiye disorders, most notahiy cancers and inflammatory disorders tee, rheumatoid arthritis, inflammatory howei disease, asthma, chronic ohstructive puimonary disease (COPE), osteoarthritis, dermatosis (ego, atopic dermatitis, psoriasis), vascuiar proiiteratiye disorders (and, atheroscierosis, restenosisi autoimmune diseases tee, ie scierosis, tissue and organ reiectioni); as weii as inflammation associated with infection (9-9» immune responses), neurodegeneratiye disorders (eg, Aizheimer’s disease, son’s disease, motor neuron disease, neuropathic pain, trieiet repeat disorders, astrocytoma, and egeneration as resuit oi iic iiver disease), ischemic iniury (on, ), and cachexia tea, acceierated muscie protein breakdown that anies various physioiogicai and pathoiogicai , (do, nerve injury, fasting, fever, acidosis, HiV infection, cancer affliction, and certain endocrinopathiesii. toes} The methods disciosed herein can he , for instance, for the treatment of cancer, As used herein, the term "cancer” refers to a ceiiuiar disorder terized try uncontroiied or disreguiated ceii proiiferatipn, decreased ceiiuiar differentiation, opriate ahiiity to invade surrounding tissue, andior apiiity to estahiish new growth at c sites. The term "cancer“ inciudes seiid tumors and hioodhorne tumors. The term ”cancer" encompasses diseases of sitin, tissues, organs, hone, cartiiage, hiood, and vesseis. The term "cancer" further encompasses primary and metastatic cancers. reset in some emhodiments, the cancer is a soiid tumor. Examnies of soiid tumors that can he treated by the methods of the present sure inciude pancreatic cancer; hiadder ; coiorectai cancer; breast cancer, inciuding metastatic breast cancer; prostate cancer, inciuding endependent and androgendndependent prostate cancer; renai cancer, inciuding, e.g., metastatic renai ceii carcinoma; hepatoceiiuiar cancer; iung cancer, inciuding, err, smaii ceii iung cancer (SCLC), nonssmaii ceii icing cancer i, hronchioioaiyeoiar carcinoma (SAC), and adenocarcinoma of the icing; ovarian cancer, ing, err, progressive epitheiiai or primary peritoneai cancer; cervicai cancer; gastric cancer; WO 67396 geai cancer; head and neck , inciuding, ea, squamous ceii carcinoma of the head and neck; meianoma; neuroendocrine cancer, inciuding metastatic neuroendocrine tumors; brain tumors, incieding, 59.9., giioma, anapiastic oiigodendrogiioma, aduit giiobiastoma mnitiforme, and aduit stic ytoma; bone cancer; and soft tissue sarcoma. {ass} in some embodiments, the cancer is a iogic maiignancy. Examoies of hematoiogic maiignancy incidde acute myeioid ieukernia (An/it); chronic myeiogenous ieukernia {Cit/it), incinding rated CML and Cit/ii, hiast phase (Ch/ELEM; acute iymphoisiastic ieukemia (ALL); chronic iymphocytic ienkernia (Cit); Hodgkin’s disease (Hi3); nonahedgkin‘s iymehoma (NHL), inciuding foiiicuiar iymnhoma and mantie ceii iymohoma; B-ceii iyrnohoma; T~ceii iymphorna; muitioie myeioma (MM); Waidenstrom's macrogiobuiinemia; myeiodyspiastic syndromes {M33}, incitiding refractory anemia (RA), refractory anemia with ringed siderhiasts , {refractory anemia with excess hiasts (RAE-23), and RAEB in transformation (RAE8~T); and myeioproiiierative syndromes. toss} in some embodiments, a physician may diagnose a patient with a cancer as nredominantiy one tyne. in some emhodiments, a physician may diagnose a patient as having more than one type of cancer. in some embodiments, the diagnosis is oredominantiy one type of myeindysoiastic syndromes. in some embodiments, the diagnosis is more than one type of myeindyspiastic syndromes. {em} in some embodiments, methods of the t disciosure are used to treat a patient having, or at risk of deyeioping or experiencing, a ence in a tumor cancer, such as ceiorectai cancer, ovarian cancer, icing cancer, breast cancer, gastric cancer, prostate cancer and pancreatic cancer. in some embodiments, methods of the present disciosure are used to treat a patient having, or at risk of deveidoing or experiencing, a ence in a iogic cancer, such as AML, Chit, CML»BP, ALL, or Cit. reset in order that this disciosure be more tuiiy understood, the foiiowing exampies are set forth.

These es are iiiustratiye eniy and are not intended to iimit the scope of the oresent disciosure in any way.

EXAMFtE§ ft. in vitre tieh Viehihty Assays {83%} The thehtei eretecei used Peiy-D~§ysiee BieCeat’“ Stack/'Cieer 384 etates (Semen Biekinsen, Frehkiih Lakes, NJ}. The apprepriate NAE inhihiter was disseived in DMSQ and ree irate the weiis using an Eche {tahcyte $uhhyvate, CA} tiquie hendiing system. mm and Titpet tines were ehteihed hem ATCC (American Type Cuiture Coitectieh, Meeassas, VA), white N84 and OCtMZ Sines were ehtaihed frem DSMZ che Semmiung ven Mikreerganismen and Zeithuituree Gth, aruhswich, Germany). Each eiete had a ceti suspensien hem we 01‘ the tines added te the weits. A parties": ef the weiis were used as ve centreis (he hd was added}, white another portien of the weiis were used as negative centreis (he cetts were added). the eiates were incubated fer 7’2 heurs, and then the ceti viahitities were measured using an ATPtite (FerkieEtmer, m, MA} essay.

Stettstieat Anetyses.

{MG} Nermaiizatien. The viahitity data was hermeiized separateiy for each mete hy seating the date se that the median 0f the negative centreis was (3 and the median e? the positive ceetmis was 1011 More formetiy, i ‘ mfldian{U+)"filfidian(U_,) where V; is the nermaiized viahihty ef the it“ weEE, U; is the raw Viehiiity measurement, medianiU) $5 the median 91‘ the negative centreis, and medieniuq is the median ef the ve controis. After izetien, the centreis were dfiscerded. tent Respense surface made! and fitting. A respense surface medefi was used te deecrihe the reiatiehehip between the hermetized viehtflity and the drug cententretiens. Fer a given piete, Eet C2€Cisfiii+(C£/i’2) xt=(CA/i})/C Elm 2 E14: sz+ E33152 +E4x3 Im1+i3x(i~--x) S :31 +Szx+53x2 +5433 V 3100 mi“" max (i+(1fC)5)”i+err0r where E, E2, E3, E4, 51, i2, i3, Sb 3;, 53, and 3,: are parameters, C; and C3 are the respective concentratinns of drugs A and B, and V is the ndrmaiized viahiiity measurements it was assumed that the error vaiues were independent and identicaiiy distributed nermai random variahies. This modei is an extension of the Hiii equation (AV. i-iiii, J. Physiot, 331d, 40, iv~viii, which is hi used to modei the effect of a singie drug. The data were fitted to this medei using the maximum iiiteiiheed method with the statistieai sdftware m R it Deveidpment Care Team (EGGS) (R: A iahguage and environment for statisticai cementing. R thundatinn for Statisticai Computing, Vienna, a. iShN 3~§fih§351rmna URL httnzi/www.R~prdieetdrgi. {tin} Queiity . Three types at duaiity checks were aphiied tn the . First, it was checked that the variatien of the positive cantrnis and the mean at the ve centreis were smaii. Next, it was checked that the new data agreed with data item previdus singie drug experiments. Finaiiy, the residuais tram the respense surface tit were ahaiyzed tn ensure that the residuai sum of squares was sufficientiy smaii. hit at these duaiity checks were based an numericai thresheids te make pass/tad decisions, and the same threshdids were used tar aii at the hiates in the experiment. it a hiate taiied any ene rat the duaiity checks, it was remdved tram the is. {£9273} Measuring in vitrd synergy. The Cdmhinatidn index (Mt; Berenhaum, .i. Them. diet, sass, 114, £13481) was used as a e at drug synergy. The Camhihatidn index is cemhuted based on an isehdiogram, which is a siice of the ddse respense surface with constant viahiiity. For the present anaiysis, the 56% isohoiegram, which is the ddse r that has 59% viahiiity, was used The ECSBA and ECSGB are defined he the respective deses of drugs A and h aiene that have a viahiiity at 59%. Fur a paint (DA, 03) aiong the 56% isohdiegram, the atinn index is d as (CPA! ECSGA} + {[35] EGGS}.

Since the chdice at (DA, Deg) can he arhitrary, the constraint DA 1' Ba 2 ECSQA ," ECSGE was used. it the Cemhinatien index is iess than I, it indicates that the isdhdidgram curves inward, and that the drug cemhinatien is synergistic. Cdnverseiy, it the Cemhinatidn index is greater than t, the 50% isohoidgram carves outward, indicating antagonism. in the mere stringent is method anniied according tn the nresent disciosnre, Combination index vaiues within the range {id-$2 are considered additive. This rate greyents smaii deviations irdrn additivity from heing ciassiiied as synergistic. {are} A two sided t~test for each cendition was nerfermed to determine if the mean Comhination index differed from :i. The Benjaminisiiochherg method (Y. denjarnini and Y. Hechherg, A it. Stat. See, Series 8 (Star. Methedeij, sass, 5? (1}, 283i~3i303 was used to adjust the reseiting e-yaiues for muitipie hypothesis testing. An adjusted dvaiue heiow £3.95 was censidered to staticaiiy significant. in erder fer a cornhinatien he he ciassiiied as synergistic, we required that three ia be met: the mean Cemhinatien index fer the cendition had tn he iess than 1, the ence had to he statisticaiiy significant, and Comhination index had to he eotside the range (3.8, 1.2). This third criteridn prevented smaii ions from additivity irern heing ciassitied as synergistic. Cemhinations fer which the e-vaine was aheve (3.05 er the Cemhinatien index was within the range (0.8, 1.2) were eiassitied as additive. {east Ceii yiahiiity assays were used to assess the carnhinatidn effect in vitro of each of two NAE inhihiters, Mthdgzd and i~216, with each of two hyndmethyiating agents, azacitidine and decitahine, in tour ceii tines, thd, QCiME, N84, and ‘i‘i-iP'i.» Figure 1 shows the atien index tar aii at the experiments that passed the duaiity checks ameng each tested comhinationi The resuits are arranged by the ion. Tahie Li, heidw, iists the mean Comhination index, the adjusted n~vaiue, and the concidsidn for each ined combination. As Tahie 1 shows, aii eight ations df NAE inhihiter and hyeomethyiating agent demonstrated a synergistic effect in bath the Omit/Q and N84 ceii tines. in the iitfiti iine, hdth NAE inhibitors demdnstrated synergy with decitahine and shdwed an additive effect with azacitidinei in the ThP-i iine, hath NAE inhibitors demonstrated an additive effect with idine. [hie tn the tacit di singie agent activity at" decitahine in Tiiii-l, a Cnnthinatinn index cannot he ated tor the in vitre experiments with NAE inhibitors and decitahine in Ti-iPn'i.

WM} Tame 1. $ummar§r a? the Cambinatim Enfiex vafiueg, E MAE Hypamethyiating Cefii Eina Number 9f Mean Adjusted Ccnciusion inhibétm agmt g P-vaiue i Combinatign index E MLNfiQN E Synergy """"‘"“““"""‘""“'“"“"""“I’m“ - Detitabém‘: GCEMZ . Synergy MLNdQZr-fl Azacétédine w: s 9.44 WWW:IIIIIIIIIII§Egg-ray .......... —216 Azacitidine E GCEME REEMQM Decitabine NM €3.61 595%;""""""""" 34 a: ________________________________________m _ MLNdQZd Azac‘stifiine €3.52 5.8x16“3 E Synergy """""""""""Kgggsgggag"""""""""" ‘ Synergy E“E;?EEE§&§§EWW"5%;532533'5;"""""" m"""""""""" W"EéQEEEéEEEé""""""""""""" i 1.1:} 2.4):10'3 Additivity {£32925} Figure it shews the Cemhination index vaiues fer each niate, arranged by the cenditinn ii.e.,, a given drug cemhinatien ahhiied tr) a given ceii tine), "i'hese resuits were summarized try cementing the mean Cnrnhination index fer each cenditien, as shewn in Tahie 1: 2. in viva “turner Efficacy Medeis‘ aneeus senegrat‘t medeis {are} Test subjects. tit-dd {2x106} turner ceiis in 100 ut nhusnhate ed saiine with ei’“ (Bi) Biosciences, Bediord, MA) were asepticaiiy injected inte the suhcutaneaus space in the right dersai flank of femaie Ncr nude mice {age Sud weeits, Charies River tahnratnries, Wiiniingtun; MA) using a 26~gauge needie. 'iiiill 053 er CECE—M2 (5x135) turner ceiis in 139 iii. ate huttered saiine with iviatrigeiTM were asepticaiiy injected into the aneous space in the right dorsai flank of temaie (£8.17 $Ciili mice (age 5—8 weeks, Charies River taheratnriesi using a 2d»gauge needie. {did} Beginning en dayi seven {7’} after inecuiatiun, turnnrs were measured twice weekiy using a r caiieer. Turner voiurnes were caicuiated using standard nrncedures {0.5 X (iength x widthzi).

When the terriers reached a voiume at apnruximateiy 200mm3, mice were randdrnized into groups of it) and injected sohcutaneeusiy with compound inhihiter {280 tit) at varieus doses and scheduies, with the first dosing day defined as Day it. hit centrei greens received vehicie aiene. Turner size and body weight were measured approximateiy twice a week fer the duratien oi the study. Mice were euthanized when their tumor vniur‘ne d mitt at their hedy weight, or when the average tumor ie at a treatment ar centrai grout) reached annreximateiy 2000mm3. The dosing scheduie fer each study was as ieiinws: Mime-92a and azacitidine were dosed senarateiy er ce—desed try suhcutaneous injection en Days 1, li, 8, 11, 15 and 18 at the indicated deses. “turner grewth continued te he mnnitered after the dosing perind. Average tumor voiurne reported as a functien at time is shown in Figures Edi. {£98833 dtatisticai Anaiyses at synergy tar turner grnwth in suhcutaneeus ait mudeis. {@813 For the THP-i‘t and 0Ci~hri2 rnedeis, measurements from dayi {i te 21 were anaiyzed. Fer the iitdti rnndei, measurements tram day (i to itti were used, since severai at the mice had tumors exceeding the aiiuwed voiur‘ne after day 145 Aii turner veiurnes had a vaiue (if 1 added to them hetnre iogm transierrnatien. These veiues were red acrdss treatment greens to assess whether the differences in the trends ever time were ticaiiy significant. “in cernnare pairs at ent groups, the feiiuwing mixedeffects iinear regressien mndei was fit tn the data using the maximum iiiteiihded methnd: ck : Yak + treat; + day; + day;2 + (treat’tdayig + (treatt‘dayziig + eijk where Yuk is the Eagle tumor vaiue at the it“ time ndint of the km animai in the ith treatment, Yank is the day 0 iegm tumdr vaiue in the if“ animai in the ifi‘ treatment, day; was the median—centered time mint and was treated as a cuntinunus variahie, and egjk is the residuai errer~ A spatiai newer iaw envariance matrix was used tu atceunt for the repeated measurements en the same animai ever time. interactinn terms as weii as day}2 terms were retrieved it they were net statistieaity significant. {£382} A iikeiiheed ratio test was used tn assess r a given pair of treatment groans exhihited differences which were statisticaiiy significant. The ~22 tog iiheiihoed at the fuii medei was tempered te one witheut any treatment terms (reduced medeii and the difference in the vaiues was tested using a Chinsquared test. The degrees at m of the test were cairniated as the difference between the degrees of freedom of the tuii made? and that at the reduced medeii E933} in addition to the tieai significance, a measure at the magnitude et the effect fer each treatment was found. The predicted differences in the ieg turner vaiues {YWYm-K} sis~ time were taken frum the aheve modei tn caicuiate mean area under the curve (AUG) vaiues for each treatment grdun. A dAUC vaiue was then caicuiated as: meant"AEJCmmE ) «w mean(AUC dAUC = 10% Hefiifllfifli ) ImeamAUC i cannot )3 {$343 For synergy anaiyses, the nhserved differenees in the iog tumor vaiues were used to ate AUC vaiues for each animai. in ces when an animai in a treatment arena was remnved from the study, the East deserved tumor vaiue was carried ferward through aii uent time points. Te imnreve the rnhustness at the synergy anaiysis, the tniiowing nrneedure was aepiied to the ADC vaiues tram each treatment greup. Let a he the set of AUC vaiues for a given treatment greup. A range et interest was defined: {medianhr} - 5 * MAifiéai, medianhr} + 5 * MAEéai).

WO 67396 Here, MAD is the median ahsoiute deviation of at it any vaioe in a teii outside this range, that veiue was reniaeed hy the vaioe at the ciosest honndary. The procedure was non—iterative, so the range was computed oniy once for each treatment group. {$853 The synergy store for the ation of treatments A and it was defined as 106 * {meaniAUCAB} »~ meaninucgi ~— UCg} + ucwii i meaniAUCmi where AUCM, AUCA, AUCB, and AUCQE are the ADC vaioes tor animais in the eomhination group, the A group, the B groan, and the controi groon, respectiveiy. The standard error of the synergy score was computed hased on the variation in the AUC vaioes among the animais. A two sided t-test was used to determine it the synergy score was significantiy different from zero. if the P-vaioe was heiow £3.05, and the synergy score was iess than zero, then the ation was ered to he synergistic. it the ihvaioe was above 0.95, then the eomhination was considered to he additive. teas} Moose xenogratt modeis were used to assess the combination effect in vivo of NAE tor itzzt and hyoomethyiating agent azacitidine. Figures 2nd show tumor voiorne as a function of time in three stihcutaneoos xenogratt modeis toiiowing treatment with the vehicie as a singie agent, MLN4§24 as a singie agent, azatitidine (“'Aza“) as a singie agent, and err-administration {so} at Mti‘tdgm and azacitidine on Days 1, ti, 8, 11, 15 and 18 at the indicated doses. test} in the Misfit) subcutaneous xenogratt modei (Fifi. 2i, Mthiitgltli and azacitidine as singie agents had a margihai effect on tumor growth. in contrast, co~dosing MLNdQZd and azacitidihe ied to tumor regressions, with a statistieai assessment of synergy. toss} in the THEE. xenograft modei (no. 3), azaeitidihe as singie agent had a marginai effect on turnor growth whereas Mthiziwd as a singie agent inhihited tumor . in contrast, co~dosing MLN4§2d and azacitidine ted to tumor regressions. fiesoite the statisticai assessment of additivity in this modei, rather than synergy, the figure eieariy shows a combination benefit: tumor growth tion {singie agent) versus tumor regression with the eomhinationi toast An additionai demonstration of improved activity in "ii-€94 is the deiay in tumor regrowth with the combination compared to each singie agent. The onai benefit provided try the combination over the singie agent treatments was statisticaiiy significant, as shown in Tahie 3h (Poi/aide <2 0.65). reset in the 0Ci~M2 subcutaneeus xenngraft ntndei (Fifi. ti), masses and azacitidine as singie agents inhibited tumor growth. in centrast, cadesing Mthi4921i and azacitidine ied tn tamer regressinns with a statisticai assessment at synergy Disseminated xenngraft medei {asst Test sdhjects. G ) tamer ceiis in mi) tit iiViDii/i media were inncuiated in the iaterai vein cit iemaie mice C847 SCED (age 8—10 weeks, Charies River teries, Wiimingten, MA) using a 27~gange needie. 0n day 20 nest—ineceiatien, mice were randemized intn greens at it). §tarting on day 22, mice were desed suhcutaneensiy with yehicie, 180 trig/kg MLNdQZa’i. 1i) mg/irg azacitidine, er the cdmhinatinn at 185 nag/kg es and 10 mgiitg azacitidine, using the same twicemweekiy scheduie as described in the subcutaneous aft experiments g on days 22, 25, 29, 32, 36, 39} The mice were rnenitered at ieast twice weeidy fer hedy weight iess and signs at disease, ing naresis er sis of hind iimhs and emergence ef naipahie and internai sniid terners~ The day an which an animai died er was sacrificed diie ta disease harden was recerded. Surviyai time is shnwn in Figure 5‘ Statisticai anaiysis ef synergy fer ai in disseminated xenagraft medei. {rise} in determine synergy in the suryiyai times, the mean suryiyai times and corresndnding standard errors were cemnuted fer each ent grants. The snrviyai synergy was defined as meanisuryiyaiwi - meanisuryiyaiAi w meanisnryiyaiy}1L meanisuryiyaimi where snryiyaihg, survivaiA, snrviyais, and aim are the survivai times for animais in the cemhinatinn green, the A group, the 8 green, and the centrei green, respectiyeiy. The standard error fer the stiryiyai synergy was found by adding the standard error nf each at the tear terms in quadrature. A twe sided Z- test was used tn determine if the suryiyai synergy was significantiy different from ternw if the P-yaiue was heiew (3.05, and the suryiyai synergy was greater than zere, then the cnmhinatinn was considered tn he synergistic. if the P-yaide was above {3135, then the atien was considered tn he additive {asst Figure 5 shdws snrvivai as a functidn of time in a disseminated xenegratt medei in which new ceiis were inocuiated by intravenous injectien, and mice were treated with yehicie, with masses as a singie agent, azacitidine as a singie agent, and ce—administratien of ac. d and azacitidine heginning en Day 22 nestuinecuiatinn at the indicated dnses, using the same twice~weeidy scheduie as in the experiments in Figures 24. in the tit—6i) disseminated mndei (HG. S), iViLi‘titigzli and azacitidine as séng§e agents betn extended mean snwévefi time mannered to the centreé green (8.4 day extensien fer MLNIIQM and 21.1 day extension fer ezecitEnSne}. The cem‘ninatinn sf MLNdQZe and azeeineine extended mean survive? time by 3%.? days. which is 7.2 days innger than wnuid be exeected fmm an aenétive enmbinetien (ME. 5}. The enwivei y wee statisticaiiy significant.

Tame 23. Synergy assessment for HLSQ subcutanenus xenngrafi tumors.

Treatment Synergy Synergy genre P~Veiue standard errnr S’Neiue Ens” the difference in effects azacitidine 15 mg/kg MLNQQM 18G neg/kg + azacitinine 15 mg/kg Tenie 3e. Synergy essesement fer THPnl subcutaneeus afi turners. nent Synergy see re : m...“............g E Reference PvVawe fer the % jeefiece § MLN4§223 18G nag/kg MLNQQE 186 mgikg + azacitidine if) mgfkg ...“...................................................... azecnidine 1n nag/kg KnLNdQZé 138 mglkg + azacitidine 1E? mgi’kg Treatment Synergy seere y score ?«Ve€ue Assessment eieneard errer LMLNQfiM 180 mgjkg + ezecitidine S mgikg Synergy Tame 4b. ?airwise camparisen 0f treatment greues fer QC§~M2 neous xenegrefi tumers“ Referenee Treated dAUC F‘nVaEue fer the eifierence in effects MLN4924 18E) Eng/kg mmeza 185} mgfkg + idine 5 mg/kg MES azacétifiine 5 rug/kg wear-324 18C! mgfkg + azecitidine S mgikg EMean survivai Standard error time (days) ' of mean Survive: time {daV$3 Treatment Survivei Survive? synergy (days) synergy standard errer {days} MLNL’QM 18C} mgfkg + azacitidine 1C9 mgjkg ‘3’ hrephetii‘; flrug stratian Examnte. {fled} hrinr to use, MLNQQEMBP viais are warmed to arnhient caneitians (15%: tn 30%?) hy piecing them at reern temeerature. Acceierated warming metheds, such as a water hath, was net, anti must net he, used. Minaazeinr is stahie at ream temperature for 8 haters nrier tn diintien. {£3953 Each Mtnaazeine viai centains neminaiiy 5 mt {5Q rng MLNAQZQ as free base}. Using steriie technique, the aperepriate veinme at drug is withdrawn from viaiia} anti inieeted inte a 258 mt EV hag cantaining a 5% dextrase saintien, which is then gentiy inverted eriiy tn mix. The prepared 4«iDh iv hag must he used within 6 hears it stared at ream temperature. Aiternativeiy, the ed EV hag is chemicaiiy stahie and can he stared far up tn 24 hours at 5°C 1 3°C. After 24 hours at starage at 5°C t 3°C, the prepared iv hag must he used within 6 hours Linen earning tn room temperature. The viai must net he shaken at anytime during rinse atinn. {has} ctinns fer the preparatinn, titntian, anti dispensatien at azacitidine are previded in the azacitidine (ViDAZA®} package insert {wit} The arnnnnt 0i manner: and azaeititiine administered is hased eh hndy surface area EBSAEQ BSA is caicniated using a standard nemegrarn nn Cycie 1, Bay 1, anti at nent visits if the patient experiences a > 5% change in hefty weight tram the weight used far the mast recent 8% caicuiation. tree} Patients receive Mtttiriazzi diiuted with 5% dextrnse in a ESQ-int EV hag via a fifinmii‘iute intusien.

Mtiiiligm shoiiid he administered threugh centrai or perinherai veneus aceess. The nn can he stewed er stepped and ted fer any asseciated infusion reactions. The tntai infusien time must net exceed six hours» tram the tirne at recehstitntian. treat The entire centent at the marines h! hag wiii he infused at a cahstant rate ever 1 heart Te ensure that aii the MLN4924 enters the hedy, the infusien iine wiii he flushed with 5% dextrnse imrnetiiateiy after istratien. intent tnstrnetians for the administratian at azaeitidine are previded in the azaeitidine {Viewer} package insert. tetra} Aithnngh {3th can ester at any paint during treatment, eniy 3th accurring during Cycie 1 of treatment wiii necessariiy influence decisians regarding ease escaiatian, exeansinn at a dose ievei, er evaiuatien at intermediate dose ieveis. nts are menitnred threugn aii cycies at therapy for treatinentnreiated texicities.

} The en ni eyeies wiii be 28 days. Azacitidine wiii be administered in a S-enfleifflen uie, i.e., en Days 1, 2, 3, 4, S, 8, and Q Mtnasza wiii be administered an Days 1, 3, and 5. Patients wiii receive both agents en Days 1, 3 and 5. Mti‘itigzti can be administered at a dese at Zti ring/ml, 3i) mg/‘rnz, fitting/me, 45 mg/mz, 5i) nag/m3, 6i) nag/mi nr 75 2. Azaeitidine wiii be administered either N or SC at a dese of 75 mgirnZ. {@1033 in an eptinnai embodiment, Minaeza wiii be administered en Days 1, 8, and 15.

Emmi; Optionaiiy, the duration at eycies wiii be 23 days, with the exeentien oi Cycie it, where a ?~day iead~in wiii be incorporated where ne azacitidine wiii be administered, such that {Zyeie 1 wiii iast a tetai of 35 days. According to this scheduie, azaeitidine wiii be administered in a E-onfzrof‘ifl—an schednie; an Days 8 te 12 and Days 13 and 16 in Cycie It, and en Bays 1, 2, 3, 4, 5, 8, and a for aii subsequent cycies.

Aeserding tn this scheduie, Minaeza wiii be administered on Days 1, 3, and 5. gems} in an anether ontienai embodiment, Mthififliitli wiii be administered on Days 1, at, it]. and 3.55 fer Cyeie 1 oniy, giving one 35 day eyeie; in aii uent eyeies, za wiii be administered en Days it, 3, and 5,, each cycie tasting 28 days. Aeenrding tn this antinnai sebeduie, patients wiii receive bath agents an Days 11 and 15 at" Cyeie 1 and en Days 1, Si, and S at subsequent eyeies. MtNdQZQ wiii be administered at a dose bf 29 mgfrnz, 3Q nag/ml, 40mgini2, 435 mg/mz, SQ mglinz, SQ nag/mg, or ?S mg/mz.

Azacitidine wiii be administered either hi or St: (physician‘s choice) at a dose at 75 mglmz. {ates} Patients wiii receive azaeitidine as either an iv er SC injeetien (see azacitidine {ViiliAZAQ} nackage insert fer detaiis an administratieni. (in days where both masses and azaeitidine are to be administered, infusien of Zi-fi wiii eemmenee at a time ranging from 15 te 653 s after eomnietien bf administratinn (if idine. An assessment at vitai signs wiii be made bre azaeitidine rinse, tire Minaem dose, and pest Minaezs dose on these days.

Claims (35)

WHAT IS CLAIMED IS:

1. Use of an NAE inhibitor chosen from ((1S,2S,4R)(4-((1S)-2,3-dihydro-1H-inden ylamino)-7H-pyrrolo[2,3-d]pyrimidinyl)hydroxycyclopentyl)methyl sulfamate or a pharmaceutically acceptable salt f, or {(1S,2S,4R)[(6-{[(1R,2S)chloromethoxy- 2,3-dihydro-1H-indenyl]amino}pyrimidinyl)oxy]hydroxycyclopentyl}methyl sulfamate, or a pharmaceutically able salt thereof, in the manufacture of a medicament for treating cancer, said treating comprising administering the NAE inhibitor in combination with a hypomethylating agent chosen from azacitidine or a pharmaceutically acceptable salt f, or decitabine or a pharmaceutically able salt thereof.

2. Use of a hypomethylating agent chosen from azacitidine or a pharmaceutically acceptable salt thereof, or decitabine or a ceutically acceptable salt thereof in the manufacture of a medicament for treating cancer, said treating comprising administering the hypomethylating agent in combination with an NAE inhibitor chosen from ((1S,2S,4R)(4- ((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or a pharmaceutically acceptable salt thereof, or {(1S,2S,4R)[(6-{[(1R,2S)chloromethoxy-2,3-dihydro-1H-indenyl]amino}pyrimidin yl)oxy]hydroxycyclopentyl}methyl sulfamate, or a pharmaceutically acceptable salt f.

3. Use of an NAE inhibitor chosen from ((1S,2S,4R)(4-((1S)-2,3-dihydro-1H-inden ylamino)-7H-pyrrolo[2,3-d]pyrimidinyl)hydroxycyclopentyl)methyl sulfamate or a pharmaceutically acceptable salt f, or {(1S,2S,4R)[(6-{[(1R,2S)chloromethoxy- 2,3-dihydro-1H-indenyl]amino}pyrimidinyl)oxy]hydroxycyclopentyl}methyl sulfamate, or a pharmaceutically acceptable salt thereof, and a thylating agent chosen from azacitidine or a pharmaceutically acceptable salt thereof, or decitabine or a pharmaceutically acceptable salt thereof, in the manufacture of a medicament for treating cancer.

4. The use of any one of claims 1 to 3, wherein the NAE inhibitor is ((1S,2S,4R)(4-((1S)- 2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or a ceutically acceptable salt thereof.

5. The use of any one of claims 1 to 3, wherein the NAE inhibitor is {(1S,2S,4R)[(6- {[(1R,2S)chloromethoxy-2,3-dihydro-1H-indenyl]amino}pyrimidinyl)oxy] hydroxycyclopentyl}methyl sulfamate, or a pharmaceutically acceptable salt thereof.

6. The use of claim 4, wherein the treating comprises administering ((1S,2S,4R)(4- ((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or a pharmaceutically able salt thereof on each of Days 1, 3, and 5 of a 28-day cycle.

7. The use of claim 6, wherein the treating comprises stering ((1S,2S,4R)(4- ((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or a pharmaceutically acceptable salt f at a dose of about 20 mg/m2.

8. The use of claim 6, wherein the ng comprises administering ((1S,2S,4R)(4- ((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or a pharmaceutically acceptable salt f at a dose of about 30 mg/m2.

9. The use of claim 6, wherein the treating comprises administering ((1S,2S,4R)(4- ((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or a ceutically able salt thereof at a dose of about 40 mg/m2.

10. The use of claim 6, wherein the treating comprises administering ((1S,2S,4R)(4- ((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or a pharmaceutically acceptable salt thereof at a dose of about 50 mg/m2.

11. The use of claim 6, wherein the treating comprises administering ((1S,2S,4R)(4- ((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or pharmaceutically acceptable salt thereof at a dose ranging from about 20 mg/m2 to about 30 mg/m2.

12. The use of any one of claims 6 to 11, wherein the treating comprises administering ((1S,2S,4R)(4-((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or ceutically acceptable salt thereof intravenously.

13. The use of any one of claims 6 to 11, wherein the treating comprises administering ((1S,2S,4R)(4-((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl) hydroxycyclopentyl)methyl sulfamate or a pharmaceutically acceptable salt thereof subcutaneously.

14. The use of any one of claims 1 to 13, wherein the hypomethylating agent is azacitidine or a ceutically acceptable salt thereof.

15. The use of claim 14, wherein the treating comprises administering idine or a pharmaceutically acceptable salt thereof on each of Days 1, 2, 3, 4, 5, 8 and 9 of a 28-day cycle.

16. The use of claim 15, the treating comprises administering azacitidine or a ceutically acceptable salt thereof at a dose of about 75 mg/m2.

17. The use of claim 15 or 16, wherein the ng comprises administering the azacitidine or pharmaceutically able salt thereof subcutaneously.

18. The use of claim 15 or 16, wherein the ng comprises administering azacitidine or pharmaceutically acceptable salt thereof intravenously.

19. The use of any one of claims 1 to 13, wherein the hypomethylating agent is decitabine or a pharmaceutically acceptable salt thereof.

20. The use of any one of claims 1 to 19, wherein the treating comprises stering the NAE tor or pharmaceutically acceptable salt thereof and the hypomethylating agent or pharmaceutically acceptable salt thereof in a single dosage form.

21. The use of any one of claims 1 to 19, wherein the treating comprises administering the NAE inhibitor or pharmaceutically acceptable salt thereof andthe hypomethylating agent or pharmaceutically acceptable salt thereof in separate dosage forms.

22. The use of any one of claims 1 to 21, wherein the cancer is a hematologic malignancy.

23. The use of claim 22, wherein the cancer is acute d leukemia (AML).

24. The use of claim 22, wherein the cancer is myelodysplastic syndromes (MDS).

25. The use of claim 24, wherein the myelodysplastic syndromes (MDS) are diagnosed as any of refractory anemia (RA), refractory anemia with ringed siderblasts (RARS), (refractory anemia with excess blasts (RAEB), and RAEB in transformation (RAEB-T).

26. The use of claim 25, wherein the diagnosis is predominantly one type of myelodysplastic syndromes.

27. The use of claim 25, wherein the diagnosis is more than one type of myelodysplastic syndromes.

28. The use of claim 22, wherein the cancer is diagnosed as any of chronic myelogenous leukemia (CML), acute lymphoblastic leukemia (ALL), chronic lymphocytic leukemia (CLL), Hodgkin's disease (HD), non-Hodgkin's lymphoma (NHL), T-cell lymphoma, multiple myeloma (MM), Waldenstrom's macroglobulinemia, myelodysplastic syndromes (MDS), and myeloproliferative syndromes.

29. The use of claim 28, wherein the diagnosis is predominantly one type of cancer.

30. The use of claim 28, wherein the diagnosis is more than one type of cancer.

31. A kit for ng cancer in a subject in recognized need thereof comprising: - at least one medicament comprising at least one dose of an NAE inhibitor chosen from ((1S,2S,4R)(4-((1S)-2,3-dihydro-1H-indenylamino)-7H-pyrrolo[2,3-d]pyrimidinyl)- 2-hydroxycyclopentyl)methyl sulfamate or a pharmaceutically acceptable salt f, or {(1S,2S,4R)[(6-{[(1R,2S)chloromethoxy-2,3-dihydro-1H-indenyl]amino}pyrimidin yl)oxy]hydroxycyclopentyl}methyl sulfamate or a pharmaceutically acceptable salt thereof, - at least one medicament comprising at least one dose of a hypomethylating agent chosen from azacitidine or a ceutically able salt f, or decitabine or a pharmaceutically able salt thereof; said kit for treating cancer further comprising dosing instructions for administering the medicaments for ent of the subject in recognized need thereof.

32. A use according to claim 1, substantially as herein described or exemplified.

33. A use according to claim 2, substantially as herein described or exemplified.

34. A use according to claim 3, substantially as herein described or exemplified.

35. A kit according to claim 31, substantially as herein described or exemplified.