RU2483732C2 - METHOD OF OPTIMISING THERAPY OF PHILADELPHIA CHROMOSOME POSITIVE LEUKAEMIA BY Ab1-TYROSINE KINASE INHIBITORS - Google Patents

Abstract

FIELD: medicine, pharmaceutics.

SUBSTANCE: group of inventions refers to medicine and may be used for treating Philadelphia chromosome positive leukaemia (Ph+ leukaemia). A method of treating chronic myeloid leukaemia (CML) or Philadelphia chromosome positive acute lymphoblast leukaemia (Ph+ALL) in a group of human patients involves the stages as follows: (a) introducing the pre-determined fixed amount of imanitib or a pharmaceutically acceptable salt thereof in human patients in need thereof, (b) selecting at least one blood sample in the specified patients for at least first three months of the therapy, (c) determining minimal plasma imanitib (C_min), and (d) specifying a dose of imanitib or the pharmaceutically acceptable salt thereof so that C_min falling within the range of 1000 ng/ml and 3000 ng/ml is achieved in each patient wherein threshold C_min 1000 ng/ml has not been achieved before specifying the dose. The group of inventions also involves the use of imanitib or the pharmaceutically acceptable salt thereof for preparing a medicine for treating Ph+ leukaemia.

EFFECT: group of inventions enables minimising or avoiding the formation of resistance, loss of effectiveness and a risk of recurrence in human patients suffering CML or Ph+ALL and treated with imanitib or the pharmaceutically acceptable salt thereof.

14 cl, 8 dwg, 2 tbl, 2 ex

Description

The present invention relates to a method for treating Philadelphia chromosome positive leukemia (Ph + leukemia) in a group of patients. In particular, the present invention relates to a method for the treatment of chronic myeloid leukemia (CML) in a group of patients.

In CML, a mutually balanced chromosomal translocation in hematopoietic stem cells (HSCs) leads to the formation of the BCR-ABL hybrid gene. This gene encodes an oncogenic fusion protein Bcr-Abl. ABL encodes a tightly regulated protein tyrosine kinase, which plays a fundamental role in the regulation of cell proliferation, adhesion and apoptosis, and the BCR-ABL hybrid gene encodes a constitutively activated kinase, which transforms KSKs to produce a phenotype that exhibits unregulated clonal proliferation, reduced ability to adhesion to brain adhesion , reduces the apoptotic response to the mutagenic stimulus, which contributes to the accumulation of gradually becoming more malignant transformations. The formed granulocytes cannot develop into mature lymphocytes and enter the bloodstream, which leads to a deficiency of mature cells and increased sensitivity to infection. ATP-competitive Bcr-Abl inhibitors have been described that protect the kinase from activating the mitogenic and anti-apoptotic metabolic pathways (e.g., P-3 and STAT5 kinases), leading to the death of cells with the BCR-ABL phenotype and, as a result, provide effective therapy against CML .

In May 2001, the N- {5- [4- (4-methylpiperazinomethyl) benzoylamide] -2-methylphenyl-4- (3-pyridyl) -2-pyrimidinamine mesylate salt (imatinib mesylate, STI571, Glivec® product) was approved by the Office Food and Drug Administration (FDA) for the treatment of CML in patients who cannot be treated with interferon alfa (IFN). As early as June 2000, the first patients with CML were included in the international randomized study of interferon and STI571 (International Randomized Study of Interferon and STI571 - IRIS). The ambitious third phase of the study was unique in both size and scope. More than 1,000 patients in 16 countries have been examined for the closest comparison between Glivec® and interferon alfa (SGO'Brien, F. Guilhot, RALarson et al., N. Engl. J. Med. 348, 2003, cc. 994-1004). Imatinib in a daily dose of 400 mg is more effective than IFN + Ara-C for newly diagnosed patients with chronic phase CML (CML-HF). Previously obtained in a five-year study, the IRIS data showed an established cumulative rate of complete cytogenetic response (PCO) in 87% of patients receiving primary treatment with imatinib, and an average survival of 89% (Druker BJ, Guilhot F., O'Brien SG, etc. N. Engl. J. Med. 355, 2006, cc. 2408-2417). It was noted that among patients who achieved PCO and the main molecular response (GMO) within 18 months from the start of treatment, there were no patients who would have progressed to an accelerated or blastic phase by 60 months.

To date, the cause of the variability of responses to imatinib mesylate in the treatment of chronic CML has not been fully established. Previous studies have focused on the cellular mechanisms of imatinib resistance. Although pharmacokinetic monitoring is widely used in various branches of medicine, for example, neurology, cardiology and psychiatry, it is rarely used in clinical oncological practice. Pharmacokinetic studies of patients with CML treated with imatinib mesylate showed that plasma concentrations of imatinib over the duration of imatinib use correlate with the dose of imatinib mesylate, and body weight or body surface area are small. Peng et al. Determined the plasma concentration of imatinib and established the regimen of imatinib administration in terms of plasma concentration (Peng B., Hayes M., Resta D. et al. J. Clin. Oncol. 22, 2004, cc.935-942) . Mahon et al. (Blood, 106, 2005, p.565A) measured the imatinib concentration in the blood with the support of the treatment regimen.

The present invention relates to a method for minimizing or avoiding the formation of resistance, loss of effectiveness and risk of relapse in human patients with CML who are treated with a Bcr-Abl tyrosine kinase inhibitor. Based on the results of studies conducted at the University of Bordeaux and the IRIS program, on the correlation of pharmacokinetic data with cytogenetic and molecular responses in newly diagnosed patients with CML in the chronic phase (CML-HF), it was unexpectedly found that treatment of CML with a Bcr tyrosine kinase inhibitor -Abl can be optimized by selecting the dose of the Bcr-Abl tyrosine kinase inhibitor for a particular patient so that a specific minimum plasma level (C _min ) is achieved in each individual patient enta. An individual dose selection for each patient is necessary, given the high degree of individual variability of the C _min value with the introduction of the same dose of the Bcr-Abl tyrosine kinase inhibitor to different patients, established in the IRIS study. The present invention provides, first of all, individual treatment regimens for individual patients with CML, based on a low threshold C _min , since it was found that this parameter correlates with an increased level of survival.

CML belongs to the group of Ph + leukemia. The results obtained in a group of patients with CML and described in the present invention can be directly transferred to the entire group of Ph + leukemia. This is due to the fact that the presence of the Philadelphia chromosome, which leads to the formation of the Bcr-Abl fusion protein, is characteristic of leukemia of the Ph + group. This protein is the target of all Bcr-Abl inhibitors.

The abbreviation "Ph + ALL" in the context of the present invention means acute lymphoblastic leukemia in the presence of the Philadelphia chromosome (Philadelphia chromosome positive acute lymphoblastic leukemia).

The term "main molecular response (GMO)" in the context of the present invention means a decrease of three orders of magnitude of BCR-ABL transcripts counted in peripheral blood using real-time quantitative reverse transcriptase polymerase chain reaction, preferably after 12 months of treatment, for example 12 months of treatment with imatinib mesylate .

The term "complete cytogenic response (PCO)" in the context of the present invention means 0% of the Philadelphia chromosome at the metaphase stage in at least 20-25 cells at the metaphase stage in bone marrow aspirate (Colombat M., Fort MP, Chollet C. et al. Haematologica, 91, 2006, pp. 162-168).

The term "treatment method" in the context of the present invention also means a method of preventing diseases specified in the present invention, i.e. prophylactic administration of a pharmaceutical composition comprising a Bcr-Abl tyrosine kinase inhibitor to healthy patients to prevent the development of the diseases of the present invention.

The terms "dose selection" and "selected dose" in the context of the present invention preferably means that the corresponding dose is increased or decreased. In a broader sense, in the present invention, the concepts of "dose selection" and "selected dose" also envisage a situation in which the dose remains unchanged.

The term "Bcr-Abl tyrosine kinase inhibitor" in the context of the present invention means organic compounds that exhibit inhibition of c-Abl or Bcr-Abl from transfected cell lysates with an IC ₅₀ value of less than 0.1 μM in in vitro kinase studies performed on immunoprecipitate studies described by BJDruker et al. Nat. Med. 2, 1996, cc. 561-566.

Thus, in a broad sense, the present invention relates to a method for the treatment of Ph + leukemia, for example, CML or Ph + ALL, in a group of patients, comprising the steps of:

(a) administering a predetermined fixed amount of a Bcr-Abl tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof to people with Ph + leukemia,

(b) taking at least one blood sample from said patients,

(c) determining the lowest plasma level (C _min ) of the Bcr-Abl tyrosine kinase inhibitor or its metabolite, as well as the degrees of GMO,

(d) assessing the separating potential of the lowest concentrations of GMOs in plasma and identifying the threshold value C _min for optimal sensitivity and specificity, for example, by analyzing the characteristic curve (Receiver Operating Characteristic - ROC curve), and

(e) selection of a dose of a Bcr-Abl tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof, used for specific patients from the indicated group of patients and, optionally, for future patients with Ph + leukemia so that the C _min value for each individual patient is equal to or exceeds the threshold value C _min set at stage (g).

More specifically, the present invention relates to a method for treating CML in a group of people, comprising the steps of:

(a) administering a predetermined fixed amount of a Bcr-Abl tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof to human patients suffering from CML in need thereof,

(b) taking at least one blood sample from said patients,

(c) determining the C _min value of the Bcr-Abl tyrosine kinase inhibitor or its metabolite, as well as the degrees of GMO,

(d) evaluating the separating potential of the lowest concentrations of GMOs in plasma and identifying the threshold value C _min for optimal sensitivity and specificity, for example, by analyzing the characteristic curve (ROC curve), and

(e) selection of a dose of a Bcr-Abl tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof, used for specific patients from the indicated group of patients and, optionally, for future CML patients, so that the C _min value for each individual patient is equal to or exceeds the threshold C value _min set in stage (g).

Using the methodology described above, it was found that the threshold C _min for the Bcr-Abl imatinib tyrosine kinase inhibitor can be about 800 ng / ml, more preferably about 1000 ng / ml. The upper limit of the plasma level corresponds to a level that is lower, but closely adjacent to the level in the blood, causing dose-limiting toxicity (DPT) in an individual patient. Typically, the observed upper limit is about 3,500 ng / ml, sometimes about 3,000 ng / ml.

Thus, according to yet another aspect, the present invention relates to a method for treating Ph + leukemia, especially CML or Ph + ALL, in a patient, comprising the steps of:

(a) administering a predetermined fixed amount of imatinib or a pharmaceutically acceptable salt thereof, for example, an oral daily dose of 400 mg or 800 mg of imatinib monomesilate salt, to patients with Ph + leukemia,

(b) taking at least one blood sample from said patient, for example, during the first 12 months of treatment,

(c) determining the C _min value of imatinib, and

(g) selecting a dose of imatinib or a pharmaceutically acceptable salt thereof so that the C _min value of said patient reaches at least about 800 ng / ml, especially from about 800 to about 3500 ng / ml, preferably C _min reaches from 1000 to approximately 3000 ng / ml imatinib.

In a broad sense, the present invention provides a method for treating Ph + leukemia, especially CML or Ph + ALL, in a human patient, wherein the dose of imatinib or a pharmaceutically acceptable salt thereof is selected so that the C _min value of said patient is maintained at least about 800 ng / ml, especially from about 800 to about 3500 ng / ml, preferably the C _min value is maintained at a level of from 1000 to about 3000 ng / ml of imatinib.

More specifically, the present invention relates to a method for treating CML in human patients, comprising the steps of:

(a) administering a predetermined fixed amount of imatinib or a pharmaceutically acceptable salt thereof to a human patient with CML in need thereof,

(b) taking at least one blood sample from said patient, for example, during the first 12 months, especially the first 3 months, more preferably the first 30 days of treatment,

(c) determining the lowest plasma level (C _min ) of imatinib, and

(g) selecting a dose of imatinib or a pharmaceutically acceptable salt thereof so that the C _min value of said patient reaches at least 800 ng / ml, especially from about 800 to about 3500 ng / ml imatinib.

In the latter method, the dose of the pharmaceutically acceptable salt of imatinib is preferably selected so that the C _min value reaches from about 1000 to about 3000 ng / ml imatinib in the patient, more preferably the C _min value is about 1000 ng / ml.

Imatinib metabolism occurs through the cytochrome P450 system, with CYP3A4 being the main isoenzyme responsible for imatinib metabolism, although CYP1A2, CYP2D6, CYP2C9 and CYP2C19 are also involved in this metabolism, but to a small extent. One important metabolite, N- {5- [4- (4-piperazinomethyl) benzoylamido] -2-methylphenyl-4- (3-pyridyl) -2-pyrimidinamine (CGP74588), detected in the blood, has a biological effect close to that imatinib, and represents approximately 20% of the initial plasma drug level in patients. Due to the inherent variability of the action of CYP enzymes (Wilkinson GR, J. Pharmacokinet. Biopharm., 24, 1996, cc. 475-490), the high variability inherent in patients was established when imatinib was exposed to patients with CML (Peng BM, Hayes M. Resta D. et al. J. Clin. Oncol. 22, 2004, cc.935-942). It was found that drugs that inhibit or induce the CYP3A4 isoenzyme affect the pharmacokinetic parameters of imatinib (Bolton A.E., Peng B., Hubert M. et al. Cancer Chemother. Pharmacol. 53. 2004, cc. 102-106 , Dutreix C., Peng B., Mehring G. et al. Cancer Chemother. Pharmacol. 54, 2004, cc. 290-294, Smith PF, Bullock JM, Booker BM et al. Pharmacother. 24 (11), 2004, cc. 1508-1514, Frye RF, Fitzgerald SM, Lagattuta TF, Hruska MW, Egorin MJ Clin. Pharmacol. Ther. 76, 2004, cc. 323-329).

Thus, in another embodiment of the present invention, there is provided a method of treating CML in human patients, comprising the steps of:

(a) administering a predetermined fixed amount of imatinib or a pharmaceutically acceptable salt thereof to a human patient with CML in need thereof,

(b) taking at least one blood sample from said patient, for example, during the first 12 months, especially the first 3 months, more preferably the first 30 days of treatment,

(c) determining the lowest plasma level (C _min ) of N- {5- [4- (piperazinmethyl) benzoylamido] -2-methylphenyl} -4- (3-pyridyl) -2-pyrimidinamine (CGP74588), and

(g) selecting a dose of imatinib or a pharmaceutically acceptable salt thereof so that the C _min value of said patient reaches at least 150, especially from about 150 to about 800 ng / ml N- {5- [4- (piperazinmethyl) benzoylamido] -2-methylphenyl} -4- (3-pyridyl) -2-pyrimidinamine.

In the latter method, the dose of the pharmaceutically acceptable salt of imatinib is preferably selected so that the C _min value of the indicated patient reaches from about 250 to about 700 ng / ml N- {5- [4- (piperazinmethyl) benzoylamido] -2-methylphenyl-4 - (3-pyridyl) -2-pyrimidinamine.

In addition, the present invention relates to the use of a Bcr-Abl tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof for the manufacture of a medicament for the treatment of Ph + leukemia, according to which:

(a) a predetermined fixed amount of a Bcr-Abl tyrosine kinase inhibitor or a pharmaceutically acceptable salt thereof is administered to human patients with Ph + leukemia,

(b) at least one blood sample is taken from said patients,

(c) determine in plasma the lowest level (C _min ) of the Bcr-Abl tyrosine kinase inhibitor or its metabolite, as well as the degrees of GMO,

(g) assessing the separating potential of the lowest concentrations of GMOs in plasma and identify the threshold value C _min for optimal sensitivity and specificity, and

(e) the dose of the Bcr-Abl tyrosine kinase inhibitor or its pharmaceutically acceptable salt, applied to certain patients from the indicated group of patients and, optionally, to future patients with Ph + leukemia, is selected in such a way that the value of C _min achieved in each individual patient is equal to or exceeds the threshold value With _min obtained in stage (g). Leukemia Ph + is preferably CML or Ph + ALL. At least one blood sample is taken in the first 12 months, especially in the first 3 months, preferably in the first 30 days of treatment.

In addition, the present invention relates to the use of imatinib or a pharmaceutically acceptable salt thereof for the manufacture of a medicament for the treatment of Ph + leukemia, in which:

(a) a predetermined fixed amount of imatinib or a pharmaceutically acceptable salt thereof, for example, an oral daily dose of 400 mg or 800 mg of imatinib monomesilate, is administered to a human patient with Ph + leukemia,

(b) at least one blood sample is taken in the first 12 months, especially in the first 3 months, in particular in the first 30 days of treatment,

(c) determining the lowest plasma level (C _min ) of imatinib, and

(g) a dose of imatinib or a pharmaceutically acceptable salt thereof is selected such that the C _min value in said patients reaches at least 800, especially from about 800 to about 3500 ng / ml imatinib, especially from about 1000 to about 3000 ng / ml imatinib . Leukemia Ph + is Ph + ALL or, preferably, CML.

Another object of the present invention relates to the use of imatinib or its pharmaceutically acceptable salt for the manufacture of a medicament for the treatment of Ph + leukemia, according to which:

(a) a predetermined fixed amount of imatinib or a pharmaceutically acceptable salt thereof, for example, an oral dose of 400 mg or 800 mg of imatinib monomesylate salt, is administered to human patients with Ph + leukemia,

(b) at least one blood sample is taken from said patient during the first 12 months of treatment, especially in the first 3 months, preferably in the first 30 days of treatment,

(c) determining the minimum plasma level (C _min ) of N- {5- [4- (piperazinmethyl) benzoylamido] -2-methylphenyl} -4- (3-pyridyl) -2-pyrimidinamine, and

(g) a dose of imatinib or a pharmaceutically acceptable salt thereof is selected such that the C _min value of said patient reaches at least 150, especially from about 150 to about 800 ng / ml, preferably from about 250 to about 700 ng / ml N- {5- [4- (piperazinmethyl) benzoylamido] -2-methylphenyl} -4- (3-pyridyl) -2-pyrimidinamine.

In one embodiment, a predetermined fixed amount refers to step (a) representing a therapeutically effective amount.

The imatinib monomesylate salt in step (a) is preferably used in the present invention, for example, at an oral daily dose of from about 200 to about 800 mg, preferably at a daily dose of about 400 mg.

The method described in the present invention is particularly useful for patients with CML rated on the Sokal scale. Methods for determining ALs are known to those skilled in the art.

Another important object of the present invention is the use of imatinib or a pharmaceutically acceptable salt thereof, especially imatinib mesylate, for the manufacture of a medicament for the treatment of Ph + leukemia, wherein the dose of the pharmaceutically acceptable salt is selected such that the C _min value of said patient is maintained at least 800 ng / ml, for example, about 1000 ng / ml.

Brief Description of the Figures

Figure 1. ROC curve analysis. An analysis of the characteristic curve (ROC) is carried out to assess the separating potential of the lowest concentrations of GMOs in plasma and to identify threshold values in plasma for optimal sensitivity and specificity. The area under the ROC curve (AUC) was 0.775 at the best sensitivity (76.5%) and specificity (70.6%) at a threshold plasma concentration of 1002 ng / ml. This threshold concentration value (1002 ng / ml) is largely associated with the presence of GMOs (the probability of a successful outcome is 7.83; 95% confidence interval, 2.58-23.76; P <0.001).

Figure 2. Graph frame chart. GMOs mean the main molecular response (three-order reduction in BCR-ABL transcription levels). The graph shows the variance around the median for patients with GMOs (34 patients, average = 1350.2 ng / ml) and for those patients who have no GMO response (34 patients, average = 885.5 ng / ml). A line through each frame is a median. The lower edge means the first quartile, and the upper line means the third quartile. The error bar indicates the minimum and maximum values. The bottom line shows the target concentration of 493.6 ng / ml (1 μM / ml) required to induce the death of BCR-ABL cells in vitro. The upper line shows a concentration of 1002 ng / ml, representing the effective threshold value of the minimum concentration of imatinib in plasma in the treatment of CML.

Figure 3. The C _min imatinib variability obtained in the IRIS study in patients each receiving a daily dose of 400 mg imatinib mesylate.

Figure 4. Distribution of C _min imatinib levels at a daily dose of 400 mg on day 29 (n = 351).

Figure 5. The minimum level of imatinib depending on body weight or body surface area.

6. Complete cytogenetic response (PCO) and the main molecular response (GMO) depending on the minimum level of imatinib (29 days).

7. Minimum plasma levels corresponding to the achievement of a complete cytogenetic response (PCO) or incomplete CO in patients with CML-HF. The top and bottom edges of the frame represent the 75th and 25th percentiles. Error bars above and below the frame represent the 90th and 10th percentiles, and dots represent the 95th and 5th percentiles.

Fig. 8. The values of event-free survival (EFS) are grouped according to the minimum pharmacokinetic indicators of imatinib levels by quartile. Group Q1 is shown by the lowest line, group Q2-Q3 corresponds to the line in the center, and group Q4 corresponds to the highest line.

The Bcr-Abl trozine kinase inhibitor used in the present invention, for example, a compound of formula I:

,

,

Where

R ₁ is 4-pyrazinyl, 1-methyl-1H-pyrrolyl; amino or amino lower alkyl substituted phenyl, wherein the amino group in each case is free, alkylated or acylated; 1H-indolyl or 1H-imidazolyl bonded to the carbon atom of the five-membered ring; or unsubstituted or lower alkyl substituted pyridyl bonded to the ring carbon atom and unsubstituted or substituted at the nitrogen atom by oxygen;

R ₂ and R ₃ each independently represent hydrogen or lower alkyl;

one or two of the radicals R ₄ , R ₅ , R ₆ , R ₇ and R ₈ is nitro, fluoro-substituted lower alkoxy or a radical of formula II:

,

,

where R ₉ denotes hydrogen or lower alkyl,

X is oxo, thio, imino, N-lower alkylimino, hydroxyimino or O-lower alkylhydroxyimino,

Y is oxygen or an NH group,

n is 0 or 1, and

R ₁₀ is an aliphatic radical having at least 5 carbon atoms, or an aromatic, aromatic-aliphatic, cycloaliphatic, cycloaliphatic-aliphatic, heterocyclic or heterocyclic-aliphatic radical, and the remaining radicals are R ₄ , R ₅ , R ₆ , R ₇ and R ₈ represent each independently hydrogen, lower alkyl, which is unsubstituted or substituted by free or alkylated amino, piperazinyl, piperidinyl, pyrrolidinyl or morpholinyl, or lower alkanoyl, trifluoromethyl, free, esterified or a verified hydroxy group, a free, alkylated or acylated amino group, or a free or esterified carboxy group, or a salt of such a compound having at least one salt formation group.

The compounds of formula I are first described in detail in patent application US 5521184, in particular in the claims and in the form of end products of working examples, the essence of which is incorporated into this application by reference. In the above definition of a compound of formula I, the radicals and symbols have the meanings given in US 5521184. Preferably, the compound of formula I is 4- (4-methylpiperazin-1-ylmethyl) -N- [4-methyl-3- (4- (pyridin- 3-yl) pyrimidin-2-ylamino) phenyl] benzamide (imatinib). Imatinib can also be obtained in accordance with the methods described in WO 03/066613.

For the purposes of the present invention, imatinib is preferably used in the form of a monomesylate salt. Imatinib monomesylate can also be obtained in accordance with the methods described in patent US 6894051, the essence of which is incorporated into the present invention by reference. In addition, the corresponding polymorphs are included in the patent, for example, the crystalline modifications described therein.

In step (a) of the method described above, a preferred daily dose of from about 200 to about 800 mg, for example, 400 mg, of monomesylate salt, is administered orally. Imatinib monomesylate can be administered in the dosage forms described in US 5521184, US 6894051, US 2005-0267125 or WO 2006/121941.

Blood sampling in patients with CML in step (b) of the methods described in the present invention can be carried out by standard methods known in the art. An appropriate method for determining the plasma level C _{min of} imatinib and N- {5- [4- (piperazinomethyl) benzoylamido] -2-methylphenyl} -4- (3-pyridyl) -2-pyrimidinamine is described by R. Bakhtiar et al. In J. Chromatogr. B.Analyt. Nechnol. Biomed. Life Sci. 768, 2002, cc. 325-340.

Examples

The following examples illustrate the present invention, but do not limit it. The examples only describe a method of using the present invention. The amounts of ingredients presented as percent by weight of the pharmaceutical composition in each of the examples are given below.

Example 1. The research plan, statistical analysis and research results in Bordeaux

The patients

Patients included in this study are at a chronic stage or at a progressive stage of CML. They came from the Department of Hematology and Blood Diseases of the Central Hospital of Bordeaux and from the Bergonie Institute of the Regional Cancer Center. All patients are treated orally with standard doses of imatinib mesylate (i.e. 400 mg or 600 mg once daily for patients with a chronic or progressive stage of CML, respectively) for at least 12 months. In a study of a group of patients, blood samples were analyzed that were taken in the interval from June 2004 to March 2006 to identify a relationship between plasma concentrations of imatinib and the response to treatment. Exclusive criteria are initiation of treatment with imatinib mesylate less than one year before the study, blast crisis before treatment with imatinib mesylate or during such treatment, blood sampling performed outside the time when there was minimal concentration, poor compliance with the treatment, identification of gene mutations (mutations) in the kinase domain in Bcr-Abl.

Quantitative response to treatment

The cytogenetic response to treatment with imatinib mesylate is evaluated using a traditional cytogenetic analysis of bone marrow metastases. Cytogenetic immunocompetent cells are defined as having PCOs, i.e. 0% Philadelphia chromosome positive metastases among at least 25 metaphase cells in bone marrow aspirate (Colombat M., Fort M.P., Chollet C. et al. Haematologica 91, 2006, cc. 162-168). Use real-time quantitative reverse transcriptase polymerase chain reaction to evaluate BCR-ABL transcript levels and quantify the molecular response (Colombat M., Fort M.P., Chollet C. et al. Haematologica, 91, 2006, cc. 162-168). Briefly, peripheral blood treated with an EDTA anticoagulant is selected for RNA extraction followed by real-time quantitative reverse transcriptase polymerase chain reaction. Total RNA is extracted from the peripheral blood cells of patients by standard methods. The counting of BCR-ABL transcripts is carried out taking into account previously made recommendations for coordinating the results (Hughes T.R., Hochhaus A. et al., Blood 108, 2006, cc. 28-37). In this regard, results are obtained using the ABL gene as a gene control, and expressed as a percentage of BCR-ABL / ABL. A standardized baseline is calculated by measuring the BCR-ABL / ABL ratio in 40 patients with CML in the chronic stage in the blood collected prior to any treatment. For each sample, this baseline is used to evaluate and measure the decrease in BCR-ABL transcript. GMOs are defined as reducing the level of the BCR-ABL transcript by at least three orders of magnitude after 12 months of treatment with imatinib mesylate (Hughes T.R., Kaeda J., Branford S. et al., New Engl. J. Med. 349, 2003, pp. 1423-1432).

Quantification of Imatinib Plasma Concentrations

Blood samples for the quantitative analysis of imatinib are taken at the stage of resistance in the range of 21-27 hours after the last injection of the drug. Plasma imatinib concentrations are determined using high performance liquid chromatography in combination with electrospray-ionizing tandem mass spectrometry (Titier K., Picard S., Ducint D. et al., Ther. Drug Monit., 27, 2005, pp. 634- 640. [Erratum, Ther. Drug Monit., 27, 2005, p. 810.]). Pure control samples of imatinib mesylate and its internal standard (imatinib-DS) were kindly provided by Novartis (Rueil-Malmaison, France). A sample of the drug, representing liquid extract by liquid, is prepared from 200 μl of plasma. Then 5 μl of the extract is injected into the chromatographic system. The high performance liquid chromatography unit consists of a separate Alliance® 2690 module (Waters, Milford, Massachusetts, USA) controlled by Masslynx® computer software. Imatinib and imatinib-D8 are separated on a reverse phase column (X-Terra® RP18, [100 × 2.1 mm, 5 μm], Waters) in an acetonitrile formate buffer gradient. Analysis of the total travel time is 6 min at a flow rate of 0.3 ml / min. The amount of imatinib is determined using tandem mass spectrometry (QuattroMicro®, Waters, Milford, Massachusetts, USA) with electrospray-ionizing positive ion interface. The cone potential is set to 40 volts for imatinib and its internal standard, and the collision energy is set to 30 electron-volts for the two compounds. Imatinib and imatinib-D8 are detected in multiple response control switchings. For quantification, the peak region corresponding to m / z 494.2 → 394.1 reaction (imatinib) is measured relative to the peak region m / z 502.2 → 394.1 reaction (internal standard). The identification of imatinib is confirmed by the second specific switching of the multiple response: m / z 494.2 → 217.2.

Statistical analysis

For quantitative variables, a comparison of the average values of the two groups is carried out using Student's t test or Wilcoxon's rank test, if necessary. If there are more than two groups, an analysis of variance or the Kruskal-Wallis test is used. For qualitative variables, the proportions are compared using the χ ² test or Fisher’s exact test as necessary. In a steady state, the variability of the minimum plasma concentrations of imatinib is expressed as the following parameters: average minimum plasma concentration, standard deviation (SD), coefficient of variation, average, first and third quartiles, maximum and minimum values of minimum plasma concentrations.

The complete cytogenetic response (PCO) and the main molecular response (GMO) are consistently compared in groups of patients responding and not responding to treatment, in connection with the average minimum plasma concentrations of imatinib. A possible correlation is revealed between GMOs and the following variables: quantitative indicators, for example, age and Sokal scale; quality indicators, for example, gender and risk group according to Sokal, late CML phase at the beginning of treatment with imatinib mesylate, administration of interferon before treatment with imatinib mesylate, daily dose level of imatinib mesylate. Any correlations between the levels of BCR-ABL transcription and the time range from the start date of treatment with imatinib mesylate to the date of assessment of the molecular analysis are evaluated.

Analysis of the ROC curve is carried out using a multivariate logistic regression model, taking into account gender and age, to assess the separating potential of the lowest concentrations of GMOs in plasma and to identify threshold values in plasma for optimal sensitivity and specificity. The results are expressed as the ratio of probabilities, 95% confidence interval, P value of the Wald test.

Bilateral P values are set for statistical tests (P <0.05 significance shown). All analyzes are performed using SAS Software (version 9.1, Carey, North Carolina, USA).

Patients Included in the Study

The study analyzes ninety-five CML patients who agreed to participate. One patient is excluded because he has a blast crisis. Twenty-five patients were excluded because they had improperly taken blood tests, i.e. samples to determine the minimum concentration of imatinib were taken outside the established time frame. One patient is excluded because he has established a weak response to treatment with imatinib: this patient has no hematopoietic response and plasma imatinib levels are below 10 ng / ml. One patient was excluded because the G250E mutation was identified in the kinase domain of Bcr-Abl. As a result, 68 patients with CML are included in the study. 50 patients and 18 patients are treated with doses of 400 mg and 600 mg of imatinib, respectively, once a day.

Variability of Minimum Plasma Imatinib Levels in Patients

Variations in the minimum plasma concentrations of imatinib for each daily dose of imatinib mesylate (400 mg and 600 mg) are shown in Table 1.1. These imatinib concentrations are highly variable and vary from 181 to 2947 ng / ml, confirming the high variability in subjects of the minimum plasma imatinib concentrations for a certain daily dose, as described previously in subjects (Peng B., Hayes M., Resta D. et al. J. Clin. Oncol. 22, 2004, cc.935-942).

Table 1.1. Variability of minimal plasma imatinib concentrations in patients (n = 68 *). Daily dose level The spread relative to the average value Average value Q25 † Q75 ‡ Mini
mum Maximum Average value CO ** KB *** 400 mg 1058 557 52.6 99.7 722 1285 181 2947 600 mg 1444 710 49.2 1315 902 1629 603 2922 * Parameters of variations in the minimum plasma concentrations of imatinib, expressed in ng / ml and presented for each daily dose of imatinib mesylate: 400 mg (50 patients) and 600 mg (18 patients). These results were obtained by analysis of blood samples (using high performance liquid chromatography coupled with electrospray-ionizing tandem mass spectrometry) in the equilibrium state in 68 patients with CML included in this study. ** Standard deviation (SD) *** Coefficient of variation expressed as a percentage (KB) † Q25 - First Quartile ‡ Q75 - third quartile

Description of Patients with Responses to Imatinib Treatment

Of the 68 CML patients enrolled in the study, 56 reached PCO after at least one year of treatment. The average value (± СО) of the minimum plasma imatinib concentrations is 1123.3 ± 616.6 ng / ml and 694.2 ± 556.0 ng / ml in patients with PCO (56 patients) and without PCO (12 patients), respectively (P = 0.02). Molecular responses in relation to the main properties of 68 CML patients, classified according to the presence or absence of GMOs, are summarized in Table 1.2. The average minimum plasma imatinib concentrations are significantly higher in the group with GMOs (1452.1 ± 649.1 ng / ml) than in the group without GMOs (869.3 ± 427.5 ng / ml, P <0.001). There are no significant differences with the daily dosing of imatinib mesylate in patients with or without GMOs. In addition, the main molecular response (GMO) to imatinib is not associated with the following properties: clinical data (age, gender), late CML phase at the start of treatment with imatinib mesylate, administration of interferon before treatment with imatinib mesylate. In addition, GMO treatment is not statistically related to the time from the start of treatment with imatinib methylate to molecular analysis: the average values (± СО) are 986 ± 427 days and 966.5 ± 560 days in groups with or without GMO, respectively (P = 0.87). Four groups of patients are compared by the date of molecular analysis (using the Kruskal-Wallis test): within 560 days from the start of treatment with imatinib mesylate (16 patients), 560-900 days after the start of treatment with imatinib mesylate (18 patients), 900-1325 days after initiation of treatment with imatinib mesylate (17 patients), more than 1325 days after initiation of treatment with imatinib mesylate (17 patients). The study shows that there is no significant difference in the levels of transcription of BCR-ABL between the four groups (P = 0.48). Thus, in the studies performed, the degree of molecular response does not depend on time.

Table 1.2. Description of patients in connection with the molecular response to treatment with imatinib. Without GMO* With GMO Value Indicators Patient No. Data**** Patient No. Data Quantitative indicators Minimum plasma imatinib concentrations *** 34 869.3 ± 427.5 34 1452.1 ± 649.1 <0.001 Age 34 50.7 ± 13.6 34 51.7 ± 13.7 0.76 Sokal score 32 0.9 ± 0.4 33 1.0 ± 0.4 0.33 Qualitative indicators Floor 0.09 male 24 70.6 17 50,0 female 10 29.4 17 50,0 Sokal risk group 0.69 <0.8 fifteen 44.1 fourteen 41.2 [0.8-1.2] 12 35.3 eleven 32,4 > 1.2 5 14.7 8 23.5 Late stage CML 0.58 Yes 26 76.5 24 70.6 no 8 23.5 10 29.4 The use of interferon before imatinib 0.62 Yes fifteen 44.1 13 38,2 no 19 55.9 21 61.8 Daily dose of imatinib 1.00 400 mg 25 73.5 25 73.5 600 mg 9 26.5 9 26.5 * GMO stands for major molecular response (a decrease of three orders of magnitude of BCR-ABL transcription levels). The main indicators for 68 patients with CML are classified depending on the presence or absence of GMOs. ** P value is estimated using Student's test for quantitative variables and χ ² test for qualitative variables. *** The minimum concentration of imatinib in plasma is expressed in ng / ml. **** Data represent mean values (± standard deviation) for quantitative indicators. For quality indicators, data are expressed as a percentage.

Threshold minimum plasma imatinib concentration for the main molecular response

Using the analysis of the ROC-curve concentration - effect, the separating potential of the lowest concentrations of GMOs in plasma is investigated (Fig. 1). For GMOs, the area under the ROC curve is 0.775 with the best sensitivity (76.5%) and specificity (70.6%) with a threshold plasma value of 1002 ng / ml imatinib. This threshold of 1002 ng / ml is largely associated with the presence of GMOs (selected probability ratio of 7.83; 95% confidence interval, 2.58-23.76; P <0.001). The diagrams of the minimum plasma imatinib concentrations show the variance around the average value (Fig. 2) for patients with GMOs (34 patients, average = 1350.2 ng / ml) and without GMOs (34 patients, average = 885.5 ng / ml). In the group of patients with GMOs, in 26 patients (76.5%) of 34 patients, plasma imatinib concentrations exceed the threshold of 1002 ng / ml, and there are no patients with plasma imatinib concentrations below 493.6 ng / ml (1 μM / L ), which is the originally described target concentration required for the death of BCR-ABL-positive cells in vitro. In the group of patients without GMOs, in 24 patients (70.6%) of 34 patients, plasma imatinib concentrations were below the threshold of 1002 ng / ml, and in 7 patients (20.6%) plasma imatinib concentrations were below 493.6 ng / ml ( 1 μM / L).

Example 2. Analysis of the data of the IRIS study

This study found that minimal steady-state plasma imatinib levels after the first month of treatment (29 days) are an important covariant for long-term clinical responses in patients with CML.

Variability from the use of imatinib has clinical applications. Achieving PCO represents a reasonable substitution of clinical benefit in CML and a corresponding measure of initial antileukemic efficacy. The time to reaching GMOs and PCOs in patients with PCOs differs in different patients with different plasma imatinib exposures combined in quartiles (p <0.025). Patients who achieved PCO in one year have imatinib concentrations in steady state after one month, and they are higher than those in those who did not reach PCO. In general, C _min values are statistically significantly higher in patients who achieved PCO during the study (on average 1009 ng / ml versus 812 ng / ml). Thus, maintaining a minimum level of imatinib equal to or approximately equal to 1000 ng / ml may be important for PCO. This result is consistent with a threshold value of about 100 ng / ml indicated in Example 1.

Patients adhering to imatinib treatment during both the first and subsequent months were admitted to this study. However, there are no variations, although patients adhered to the prescribed dosage throughout this study. Although adherence to therapy is a critical parameter for the accuracy and validity of pharmacokinetic analysis, it was reasonable to assume that plasma levels of imatinib and CGP74588 were in equilibrium at day 29 in this well-controlled clinical study. The patients involved in this study were again diagnosed with a deadly disease in the early stages of treatment - i.e. at such a stage when there is an intensive consumption of daily doses of imatinib, a relatively well-tolerated drug. A significant number of refusals to use a physician-prescribed imatinib in this study is unlikely for most patients. Of the 553 patients involved in the imatinib treatment group, approximately 20% of patients increase the clinical dose to 600-800 mg / day, and the average dose increase time is 22 months (data not shown). Lax adherence to imatinib has been documented in patients with CML and can significantly affect clinical responses and the correlation between clinical response and pharmacokinetic exposures.

A correlation was established between the degree of GMO and exposure to imatinib. The established degree of GMO was significantly lower in patients with low levels of imatinib; only 25% of all patients with imatinib levels <647 ng / ml achieve GMOs by 1 year of treatment, and 40% of patients with higher imatinib levels achieve this response within 1 year. By 4 years old, 53% of patients in Q1 achieve GMOs despite low steady-state imatinib levels (29 days) compared with patients in Q4 (and 72% of patients in the intermediate quartile range - IQ). GMOs are a prognostic factor for long-term efficacy and survival. Patients who have lost GMOs have an increased rate of disease progression. Early dose selection for patients with low levels of steady-state imatinib may increase the duration of effective action.

In addition to the degree of response of PCO and GMOs, the pharmacokinetics of the minimal level of imatinib seems to be a parameter that correlates with unexpanded survival, although no statistically significant difference has been established. Uninhabited survival is a complicated event that can be disrupted by various factors, for example, the availability of other methods of treatment, increasing the dose in the patient's body at a late stage of treatment, etc. However, patients with a low level of imatinib have a poor incidence of survival compared to patients with elevated levels of imatinib. The assumption was confirmed that imatinib exposure correlates with the degree of interruption. Patients in a lower quartile have the highest degree of interruption compared to intermediate and higher quartiles. It is interesting to note that one of the reasons for the interruption is associated with an unsatisfactory therapeutic effect, compatible with the results of the correlation analysis between the clinical response (PCO or GMO) and the concentrations of imatinib in quartile.

The present invention describes steady state levels. Similar results are observed for the main active metabolite, CGP74588. However, evaluating the relatively small contribution of the metabolite to imatinib exposure (<20%), the measurement of the initial drug in plasma is the main active ingredient for the manifestation of the biological effect. If imatinib metabolism changes, for example, due to a CYP inhibitor or inducer, measurement of both imatinib and the metabolite may be required.

Thus, the exposure of imatinib to steady state in plasma, measured after the first month of treatment with a standard dose of 400 mg, correlates with long-term cytogenetic and molecular responses. Patient demographics include age, gender, and body weight, which have a minimal effect on plasma imatinib exposure, given the high degree of exposure variability between patients. Maintaining minimum plasma levels equal to or higher than the average concentration in the group of approximately 1000 ng / ml may be important for the response in the form of a complete cytogenetic response (PCO) and the main molecular response (GMO), unmatched survival and satisfactory therapeutic efficacy in patients with CML-HF. Any factors that may affect imatinib exposure, such as drug absorption, metabolism, and interactions with previous treatment, may affect the ability to achieve maximum therapeutic effect. Information on the exposure of imatinib in the blood during treatment is important, acting as a promising tool for treatment and deserving of recognition.

Methods

Patients included in this study were enrolled in the IRIS program and randomly assigned to the initial treatment with imatinib at a dose of 400 mg / day. The study design and characterization of all 553 patients randomized to treatment with imatinib include age, gender, body weight, body surface area, as well as the results described previously (O'Brien SG, Guilhot F., Larson RA et al. New Engl. J. Med., 348, 2003, cc.994-1004).

The degrees of PCO (expressed as a percentage of cells with the Philadelphia chromosome, Ph +, at the metaphase stage of at least 20 cells) in the study group and the main molecular response (GMO, expressed as a decrease of at least three orders of magnitude of the ratio BCR-ABL / BCR relatively standardized baseline levels) in subjects who have achieved PCV have been described previously (O'Brien SG, Guilhot F., Larson RA et al., New Engl. J. Med., 348, 2003, cc.994-1004).

This example focuses on those 351 patients who had available measurements of PK. Event-free survival is assessed up to 5 years and recorded by registration of clinical studies until the following events occur: death for any reason, loss of GMOs, loss of a complete hematopoietic response, or progression to a late or blastic phase. Live patients are monitored for life. The PCO indicator is estimated up to 5 years. Achievement of GMOs is analyzed only within 24 months after the start of treatment due to insufficient data after this period. The distribution of patients (with available information from the Republic of Kazakhstan) and the reasons for discontinuing treatment after 5 years are tabulated, taking into account cross or other treatment regimens, side effects, poor treatment outcome and other reasons (including a violation of the methodology, the need to continue the study (because of for bone marrow transplantation), violation of the protocol, withdrawal by the subject of consent to participate in the study, inability to bring the study to the end and death).

Analysis of pharmacokinetic samples

Blood samples are taken before dosing imatinib on day 2 (i.e., 24 hours after the first dose) and again on day 29 (steady low level). Plasma concentrations of imatinib and CGP74588 are determined by liquid chromatography and tandem mass spectrometry (LC / MS / MS). The counting limit is 5 ng / ml for both imatinib and CGP74588; the study is fully confirmed (Bakhtiar R., Lohne J., Ramos L. et al. in J. Chromatog, Anal Technol Biomed Life Sci, 768, 2002, cc. 325-340). The reliability is 104% ± 6% at the lower limit of calculation and from 99% ± 5% to 108% ± 5% over the entire concentration range of 4-10000 ng / ml.

Data analysis

The minimum plasma concentrations (C _min ) of imatinib and its metabolites after the first dose at steady state are analyzed and correlations are analyzed with clinical responses, including PCO and GMO, as well as the distribution of patients after 2 and 5 years of treatment. The correlation of the pharmacokinetic minimum levels with age, gender, body weight and body surface area is evaluated. Minimum plasma levels of both imatinib and CGP74588, on days 2 and 29, are grouped into four quartiles. The lowest quartile (Q1) includes data from 25% of patients who had the lowest concentrations, and the quartiles Q2 and Q3 include concentrations 25% above and below the average, respectively. The upper quartile (Q4) includes 25% of patients with the highest concentrations. Central 50% of the data, i.e. including Q1 and Q4, are combined in all analyzes and are denoted by intermediate qualities (IQ). These three groups (Q1, IQ and Q4) are used for the corresponding stratification. The degrees of cytogenetic and molecular response are determined using the Kaplan-Meier method, and the layers are examined by comparison with a log-rank test. The correlation between the minimum levels and demographic variables is estimated using the Spearman rank correlation coefficient.

results

Demographic indicators and minimum plasma levels of imatinib and its metabolites

A total of 351 patients (221 men and 130 women) receive pharmacokinetic data. The average body weight is 85.9 ± 16.8 (SD) kg for men (average value 83.6, variation from 52.9 to 163.3) and 72.4 ± 18.1 kg for women (average value 68, 9, variation from 40.0 to 133.0). The average body surface area is 2.0 ± 0.2 m for men (average 2.0, varying from 1.53 to 2.8) and 1.8 ± 0.2 m for women (average 1.75, varying from 1.35 to 2.54). The average age in the group is 50 years (varies from 18 to 70 years). Of the 351 patients who had measurable samples in the pharmacokinetic sub-study, 238 remained in the study (67.8%), 10 crossed (2.8%), 113 (32.2%) stopped taking imatinib due to insufficient therapeutic effect ( n = 51, 14.5%), side effects (n = 15, 4.3%), death (n = 6, 1.7%), bone marrow transplantation (n = 11, 3.1%), recall patient consent to participate in the study (n = 15, 4.3%) or other reasons, for example, violation of procedures, deviations from the protocol, inability to complete the study, administrative problems (n = 15, 4.3%).

After the first 400 mg dose, 24-hour concentrations of imatinib and CGP74588 were 517.7 ± 369.6 ng / ml and 82.7 ± 47.4 ng / ml, respectively. On day 29, the concentrations of imatinib and CGP74588 were 979.0 ± 529.6 ng / ml and 241.9 ± 105.5 ng / ml, respectively; the ratio of the concentration of the metabolite to the concentration of the drug is 0.268 ± 0.085 (n = 351). Based on the minimum levels on days 2 and 29 of the same subject, the degree of accumulation at the time of the onset of stable equilibrium is 2.21 ± 1.15 for imatinib and 3.38 ± 1.54 for CGP74588. The distribution of the concentrations of imatinib in a steady state is shown in Fig.4. 19 patients on day 29 with levels> 2000 ng / ml for analysis included in the 4th quartile.

The minimum level of imatinib is slightly higher in women compared with men (1078 ± 514.5 ng / ml versus 921 ± 530.8 ng / ml, respectively, the difference is 17.2%), probably due to the difference in weight between the sexes (18 , 7%). Minimum plasma levels for the metabolite CGP74588 give a similar result, although the ratio of metabolite / parent drug is the same in males and females. A weak correlation is observed between stable minimal imatinib levels and body weight (r ² = 0.015) or body surface area (r ² = 0.038), as shown in FIG. 5. Given the simple linear relationship between body weight and the minimum level, an increase in body weight from 40 kg to 120 kg can lead to the expected decrease in the minimum level to about 280 ng / ml. A weak correlation is also observed between the minimum levels (metabolite / parent drug ratio) and the age of the patients (r ² = 0.02). Also, given the simplified assumption of a linear relationship, the minimum imatinib levels increase by 295 ng / ml as the age increases from 20 years to 70. However, due to the large variability in plasma imatinib levels between patients, the following indicators: age, gender, body weight, and area body surfaces probably do not have clinical significance due to exposure to imatinib.

Exposure correlation of pharmacokinetic parameters with clinical responses

Table 2 lists the minimum stable levels of imatinib, CGP74588 and their ratio, grouped by quartile. Minimum exposures in Q2 and Q3 are combined in IQ to represent a 50% group. Fig. 6 (upper panel) shows that the degree of PCO response after 5 years varies significantly in quartiles with different minimum imatinib levels (p = 0.0125). The difference is mainly characteristic of the lower value of PCO in the Q1 group (p = 0> 005, Q1 versus other quartiles). A similar trend is observed for GMO degrees after 2 years relative to plasma exposure levels at steady state. Patients in Q1 have a lower degree of GMO compared with other combined groups, although there is no statistically significant difference among the three separate quartile groups (p = 0.08). The minimum exposure of imatinib in patients who eventually achieved PCO was significantly higher than the corresponding values in those patients who did not reach PCO, 1009 ± 544 ng / ml versus 812 ± 409 ng / ml, respectively (p = 0.01, Fig. 7 ) There is no significant difference in the pharmacokinetic exposure in patients who produce GMOs and those who do not produce GMOs. Statistical analysis of the degree of GMOs is carried out up to 24 months due to the limited amount of data.

There is a tendency to associate unexpressed survival with minimal levels of imatinib, namely, the relatively low magnitude of unexpanded survival in the Q1 group compared to other quartiles. However, no statistically significant differences are obtained based on the available data (Fig. 8). A similar trend is observed in the correlation between the distribution of patients (or interruption) and pharmacokinetic minimum levels (Table 2.3). After 2 years, the number of patients continuing treatment was low in the Q1 group, 75.9%, compared with 84.3% and 89.5% in the IQ and Q4 groups.

After 5 years, the number of patients continuing treatment was 58.6%, 72.5%, and 76.7% in the Q1, IQ, and Q4 groups, respectively. The main reason for the interruption of the study is associated with an unsatisfactory therapeutic effect, 10.3%, 6.2% and 4.7% in groups Q1, IQ and Q4, respectively, after 2 years of treatment, and 18.4%, 14.6% and 8.1%, respectively, after 5 years of treatment. Approximately equal degrees of side effects or interruption of treatment due to death in different quartiles are observed after 2 and 4 years of treatment. There were no patients in the Q4 group overlapping in treatment with other treatment regimens (the interferon treatment group), compared with 4.6% and 3.4% in the Q1 and IQ groups, respectively. Simultaneous other treatment is observed mainly in the first or second year after the start of treatment.

The clinical response (PCO, GMOs, or survival) or patient distribution also correlates with the minimum metabolite levels of CGP74588, since the levels of the parent drug are highly correlated (0.76, Spearman's rank correlation coefficient). The minimum plasma level after the 1st dose also shows a correlation with the responses of PCO and GMOs, but it is considered as a less prognostic parameter compared with the minimum level at steady state.

Table 2.1 The minimum levels of imatinib and CGP74588 in steady state (mean value (± SD) [range]) for quartiles Data for 29 days Total
N = 351 Quartile 1
N = 87 Quartiles 2 and 3
N = 178 Quartile 34
N = 86 Imatinib (ng / ml) 979 (± 529.6 [153.3910]) 490 (± 119.7)
[153,644] 889 (± 148.2)
[647.1170] 1661 (± 602.0)
[1180,3910] CGP74588 (ng / ml) 242 (± 105.5) [50.2, 841] 153 (± 48.5)
[50.2, 322] 236 (± 65.8)
[105,455] 343 (± 126.1)
[160,841] CGP74588 / imatinib 0.27 (± 0.085)
[0.11.0.84] 0.32 (± 0.106)
[0,15,0,84] 0.27 (± 0.068)
[0.11.0.51] 0.21 (± 0.052)
[0,13,0,36]

Table 2.2 The degrees of PCO and GMOs (%) at different minimum levels of imatinib at steady state in quartiles. results Quartile 1
N = 87 Quartiles 2 and 3
N = 178 Quartile 34
N = 86 PCO (% [95% CI]) 1 year 59 [48, 70] * 71 [64, 78] 73 [63, 83] 2 year 73 [63, 83] 80 [73, 86] 84 [75, 92] 4 year 81 [71, 91] 87 [81, 93] 89 [82, 96] GMOs (%) in patients with PCO 1 year 43 [28, 59] 56 [47, 66] 55 [41, 68] 2 year 63 [49, 78] 78 [69, 86] 86 [76, 96] 4 year 65 [50, 80] 83 [75, 91] 90 [81, 100] Time to PCR (months [95% CI]) 8.3 [2.7, 56.9] 5.7 [2.7, 50.4] 5.6 [2.8, 55.3] Time before the occurrence of GMOs in patients with PCO (months) 16.7 [2.8, 59.0] 11.5 [2.7, 59.0] 12.2 [2.8, 52.4]

Table 2.3 The distribution of patients after 2 years and 5 years of treatment in groups formed by the minimum level of imatinib in a stable state results Quartile 1
N = 87
n (%) Quartiles 2 and 3
N = 178 n (%) Quartile 34
N = 86
n (%) The condition of patients after 2 years The number of patients currently available 66 (75.9) 150 (84.3) 77 (89.5) Treatment overlaps with another treatment group 4 (4.6) 6 (3.4) 0 (0) Interrupted treatment: 1. Poor result 9 (10.3) 11 (6.2) 4 (4.7) 2. Side effects (effect) 3 (3.4) 5 (2.8) 2 (2.3) 3. Death 0 3 (1.7) 1 (1.2) 4. Other reasons * 9 (10.3) 9 (5.1) 2 (2,3) Patient status after 5 years The number of patients currently available 51 (58.6) 129 (72.5) 66 (76.7) Treatment overlaps with another treatment group 4 (4.6) 6 (3.4) 0 (0) Interrupted treatment: 1. Poor result 16 (18.4) 26 (14.6) 7 (8.1) 2. Side effects (effect) 4 (4.6) 5 (2.8) 6 (7.0) 3. Death 1 (1,1) 4 (2.2) 1 (1,2) 4. Other reasons * 15 (17.2) 14 (7.9) 6 (7.0) * Other reasons include: violation of the procedure, there is no need to continue the study (bone marrow transplantation), violation of the protocol, the subject revoked his consent to participate in the study, the inability to complete the study, administrative problems.

Claims (14)

1. A method of treating chronic myeloid leukemia (CML) in a group of human patients, comprising the steps of:
(a) administering a predetermined fixed amount of imatinib or a pharmaceutically acceptable salt thereof to human patients with CML in need thereof,
(b) taking at least one blood sample from said patients during the first three months of treatment,
(c) determining the minimum plasma level (C _min ) of imatinib,
and (g) selecting a dose of imatinib or a pharmaceutically acceptable salt thereof, so that a C _min value between 1000 ng / ml and 3000 ng / ml is achieved in each patient whose threshold value C _min 1000 ng / ml has not been reached before dose selection. 2. The method according to claim 1, wherein the imatinib monomesylate salt is administered. 3. The method according to claim 2, in which at the stage (a) a daily dose of about 200 to about 800 mg of imatinib monomesylate salt is administered orally. 4. The method according to claim 2, in which at stage (a) a daily dose of approximately 400 mg of imatinib monomesylate salt is administered orally. 5. The method according to any one of claims 1 to 4, in which at least one blood sample is taken in the first 30 days of treatment. 6. The method according to any one of claims 1 to 5, in which dose selection is performed only for patients having a Sokal score. 7. A method for the treatment of acute lymphoblastic leukemia positive for the Philadelphia chromosome (Ph + ALL) in a group of human patients, comprising the stages of:
(a) administering a predetermined fixed amount of imatinib or a pharmaceutically acceptable salt thereof to human patients with Ph + ALL in need thereof,
(b) taking at least one blood sample from said patients during the first three months of treatment,
(c) determining a minimum plasma level (C _min ) of imatinib, and
(d) selecting a dose of imatinib or a pharmaceutically acceptable salt thereof, so that a C _min value between 1000 ng / ml and 3000 ng / ml is achieved in each patient in whom a threshold value of C _min 1000 ng / ml was not reached before the selection doses. 8. The method according to claim 7, in which the salt of imatinib monomesylate is administered. 9. The method of claim 8, wherein in step (a), a daily dose of about 200 to about 800 mg of imatinib monomesylate salt is administered orally. 10. The method of claim 8, wherein in step (a), a daily dose of approximately 400 mg of imatinib monomesylate salt is administered orally. 11. The method according to any one of claims 7 to 10, in which at least one blood sample is taken in the first 30 days of treatment. 12. The method according to any one of claims 7 to 10, in which dose selection is performed only for patients having a Sokal rating. 13. The use of imatinib or a pharmaceutically acceptable salt thereof for the manufacture of a medicament for the treatment of Ph + leukemia, according to which:
(a) a predetermined fixed amount of imatinib or a pharmaceutically acceptable salt thereof is administered to human patients with Ph + leukemia,
(b) at least one blood sample is taken from said patients during the first three months of treatment,
(c) determine the minimum plasma level (C _min ) of imatinib,
(d) doses of imatinib or a pharmaceutically acceptable salt thereof are selected so that a C _min value between 1000 ng / ml and 3000 ng / ml is achieved in each patient whose threshold value C _min 1000 ng / ml has not been reached before selection doses. 14. The use of claim 13, wherein the Ph + leukemia is acute lymphoblastic leukemia positive for the Philadelphia chromosome (Ph + ALL).

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