WO2008109057A1

WO2008109057A1 - Organic compounds and their uses

Info

Publication number: WO2008109057A1
Application number: PCT/US2008/002831
Authority: WO
Inventors: Andrew Kung; David Ziegler
Original assignee: Dana-Farber Cancer Institute, Inc.
Priority date: 2007-03-02
Filing date: 2008-03-03
Publication date: 2008-09-12

Abstract

The present invention relates to methods of treating neoplasms, particularly involving brain tumors, including gliomas and glioblastomas, comprising the combination of a growth factor receptor inhibitor with a compound that inhibits the binding of the second mitochondria-derived activator of caspase (Smac) protein to inhibitor of apoptosis (IAPs) (IAP inhibitor), and one or more pharmaceutically active agents; pharmaceutical compositions comprising said combination; and a commercial package comprising said combination.

Description

ORGANIC COMPOUNDS AND THEIR USES

Related Application

This application claims priority to U.S. Provisional Application No. 60/892,692, filed March 2, 2007, titled "Organic Compounds and Their Uses." The contents of any patents, patent applications, and references cited throughout this specification are hereby incorporated by reference in their entireties.

Field of the Invention The present invention relates to methods of treating neoplasms, particularly involving brain tumors, including gliomas and glioblastomas, comprising the combination of a growth factor receptor inhibitor with a compound that inhibits the binding of the second mitochondria-derived activator of caspase (Smac) protein to inhibitor of apoptosis (IAPs) (IAP inhibitor), and one or more pharmaceutically active agents; pharmaceutical compositions comprising said combination; and a commercial package comprising said combination.

Background of the Invention

Gliomas are the most common primary malignant brain tumor in adults. Despite increasingly aggressive treatments, which combine surgery, radiotherapy and chemotherapy, the prognosis for high-grade gliomas is still very poor and has remained substantially unchanged over the last decades. The treatment of malignant gliomas remains one of the greatest challenges facing adult and pediatric oncologists today. At the most severe end of the spectrum is Glioblastoma multiforme (GBM) - among the most malignant of cancers, with a median survival of only 12 months and an inherent resistance to both chemo- and radio-therapeutics. While initial treatment of GBM with surgery, radiotherapy and chemotherapy often produces some palliation of symptoms, these tumors almost universally recur with an unrelenting progression to death.

A recent strategy adopted in an attempt to improve treatment outcomes has been to target growth factor receptor tyrosine kinases. A variety of growth factor pathways are instrumental in the tumorigenesis of gliomas and have been validated as therapeutic targets. Epidermal growth factor receptor (EGFR) amplification is the most common genetic abnormality in adult high-grade gliomas, and EGFR overexpression has been demonstrated in up to 85% of cases. Gliobastomas also often express EGFRvIII, a constitutively active genomic deletion variant of EGFR. Similarly, insulin-like growth factor- 1 receptor (IGFlR) has been shown to be abnormally active in gliomas and its inhibition to prevent tumor growth. Malignant gliomas also often exhibit over- expression of both platelet derived growth factor (PDGF) and platelet derived growth factor receptor (PDGFR), which contribute to tumor progression via an autocrine or paracrine loop.

Gliomas are characterized by resistance to apoptosis via a multitude of cell signaling pathways. The PDK / AKT pathway is highly dysregulated, the pro-apoptotic p53 is often mutated while the pro-apoptotic MDM2 protein is over-expressed, and the BCL-2 family of proteins are dysregulated. The inhibitor of apoptosis proteins (IAPs) represent the final molecular blockade preventing apoptosis by inhibiting the activity of caspases 3, 7 and 9. They have been shown to be highly expressed in malignant gliomas. The IAP survivin has been identified in the majority of malignant gliomas and its levels shown to correlate inversely with prognosis.

While growth factor receptors have been validated as therapeutic targets in gliomas, strategies seeking to inhibit their activity have met with limited success. Poor responses may be due to the resistance to apoptosis that is intrinsic to gliomas. Accordingly, there remains a need for agents that can inhibit the activity of growth factor receptors, as well as for treatments of diseases and disorders related to growth factor receptor activity.

Summary of the Invention

There remains a need for the treatment of neoplasms and tumors, particularly involving brain tumors, including gliomas and glioblastomas. Accordingly, in one aspect, the invention provides a method of treating a tumor in a subject in need thereof, comprising administering to said subject a therapeutically effective amount of a combination comprising a growth factor receptor inhibitor with an IAP inhibitor. In one embodiment, the IAP inhibitor inhibits the binding of the second mitochondria-derived activator of caspase (Smac) protein to inhibitor of apoptosis (IAPs) (IAP inhibitor). In another embodiment, the growth factor receptor inhibitor is selected from the group of: i) a platelet-derived growth factor (PDGF) receptor tyrosine kinase inhibitor; ii) a human epidermal growth factor type 1 /epidermal growth factor receptor (HER1/EGFR) inhibitor; iii) epidermal growth factor (EGF) receptor protein tyrosine kinase inhibitor; iv) inhibitors of the insulin-like Growth Factor I Receptor; and v) combinations thereof.

In another embodiment of the invention, the PDGF receptor tyrosine kinase inhibitor is selected from a compound of formula III, IV, and combinations thereof. In another embodiment of the invention, the IAP inhibitor is a compound of formula I. In certain embodiments, the compound of formula I is N-[l-cyclohexyl-2-oxo-2-(6- phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2-methylamino-propionamide. In other embodiments, the compound of formula I is (5)-N-((5)-l-cyclohexyl-2-{(5)-2- [4-(4-fluoro-benzoyl)-thiazol-2-yl] -pyrrolidin- 1 -yl } -2-oxo-ethyl)-2-methylamino- propionamide. In another aspect, the invention provides a pharmaceutical composition comprising a combination comprising a growth factor receptor inhibitor with an IAP inhibitor, optionally together with a pharmaceutical carrier. In one embodiment, the IAP inhibitor is a compound of formula I. The compound of formula I can be N-[I- cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2- methylamino-propionamide or (S)-N-((S)- 1 -cyclohexyl-2- { (S)-2- [4-(4-fluoro-benzoyl)- thiazol-2-yl]-pyrrolidin-l-yl}-2-oxo-ethyl)-2-methylamino-propionamide. The pharmaceutical composition can be used for the treatment of neoplasms, particularly involving brain tumors, including gliomas and glioblastomas.

In another aspect, the invention provides a commercial package comprising a combination of a compound of formula I and III useful in glioma treatment, together with instructions for simultaneous, separate or sequential use thereof in the treatment of gliomas. The invention also provides a commercial package comprising a combination of a compound of formula I and IV useful in glioma treatment, together with instructions for simultaneous, separate or sequential use thereof in the treatment of gliomas. In another aspect, the invention provides a use of a combination of a compound of formula I and III for the preparation of a medicament for the treatment of gliomas; as well as a use of a combination of a compound of formula I and IV for the preparation of a medicament for the treatment of gliomas. In one embodiment of these combinations, the compound of formula I is N-[l-cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3- c]pyridin-l-yl)-ethyl]-2-methylamino-propionamide. In another embodiment of these combinations, the compound of formula I is (5)-N-((5)-l-cyclohexyl-2-{(5)-2-[4-(4- fluoro-benzoyl)-thiazol-2-yl]-pyrrolidin- 1 -yl } -2-oxo-ethyl)-2-methylamino- propionamide.

In another aspect, the invention provides a combination comprising a therapeutically effective amount of a growth factor receptor inhibitor with an IAP inhibitor. In one embodiment, the IAP inhibitor is a compound of formula I. In one embodiment of the combination, the compound of formula I is N-[l-cyclohexyl-2-oxo-2- (6-phenethyl-octahydro-pyrrolo [2,3 -c]pyridin- 1 -yl)-ethyl] -2-methylamino- propionamide. In another embodiment of the combination, the compound of formula I is (S)-N-((S)- 1 -cyclohexyl-2- { (S)-2- [4-(4-fluoro-benzoyl)-thiazol-2-yl] -pyrrolidin- 1 -yl } -2- oxo-ethyl)-2-methylamino-propionamide.

In another aspect, the invention provides a pharmaceutical composition comprising (5)-N-((5)-l-cyclohexyl-2-{(5)-2-[4-(4-fluoro-benzoyl)-thiazol-2-yl]- pyrrolidin-l-yl}-2-oxo-ethyl)-2-methylamino-propionamide and PKI166. In another aspect, the invention provides a pharmaceutical composition comprising (S)-N-((S)-l- cyclohexyl-2- { (S)-2- [4-(4-fluoro-benzoyl)-thiazol-2-yl] -pyrrolidin- 1 -yl } -2-oxo-ethyl)-2- methylamino-propionamide and AEW541. In yet another aspect, the invention provides a pharmaceutical composition comprising (S)-N-((S)-l-cyclohexyl-2-{(£)-2-[4-(4-fluoro- benzoyl)-thiazol-2-yl] -pyrrolidin- 1 -yl } -2-oxo-ethyl)-2-methylamino-propionamide and AMΝ107. In still another aspect, the invention provides a pharmaceutical composition comprising (5)-N-((₁S)-l-cyclohexyl-2-{(5)-2-[4-(4-fluoro-benzoyl)-thiazol-2-yl]- pyrrolidin-l-yl}-2-oxo-ethyl)-2-methylamino-propionamide and imatinib. In another aspect, the invention provides a pharmaceutical composition comprising N-[I- cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2- methylamino-propionamide and PKI 166. These pharmaceutical compositions can be used to treat neoplasms, particularly involving brain tumors, including gliomas and glioblastomas. In another aspect, the invention provides a pharmaceutical composition comprising N-[ 1 -cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin- 1 - yl)-ethyl]-2-methylamino-propionamide and AEW541. In still another aspect, the invention provides a pharmaceutical composition comprising N-[l-cyclohexyl-2-oxo-2-

-A- (6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2-methylamino-propionamide and AMNl 07. In yet another aspect, the invention provides a pharmaceutical composition comprising N-[I -cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3- c]pyridin-l-yl)-ethyl]-2-methylamino-propionamide and imatinib. These pharmaceutical compositions can be used to treat neoplasms, particularly involving brain tumors, including gliomas and glioblastomas.

Brief Description of the Drawings

Figure 1 shows an initial assessment of an IAP inhibitor on glioma cell proliferation using a MTS assay.

Figures 2 A, 2B, 2C and 2D demonstrate the anti-tumor effect of the combinations of the invention.

Figures 3 A, 3B, and 3C demonstrate the anti-tumor effect of the combinations of the invention. Figures 4A, 4B, 4C and 4D demonstrate the anti-tumor effect of the combinations of the invention.

Figures 5A and 5B demonstrate the in vivo anti-tumor effect of the combinations of the invention.

Detailed Description of the Invention

Definitions

The term "alkyl" includes saturated aliphatic groups, including straight-chain alkyl groups (e.g. , methyl, ethyl, propyl, butyl, pentyl, hexyl, heptyl, octyl, nonyl, decyl, etc.), branched-chain alkyl groups (isopropyl, tert-butyl, isobutyl, etc.), cycloalkyl (alicyclic) groups (cyclopropyl, cyclopentyl, cyclohexyl, cycloheptyl, cyclooctyl), alkyl substituted cycloalkyl groups, and cycloalkyl substituted alkyl groups. Furthermore, the expression "C_x-C_y-alkyl", wherein x is 1-5 and y is 2-10 indicates a particular alkyl group (straight- or branched-chain) of a particular range of carbons. For example, the expression Ci-C₄-alkyl includes, but is not limited to, methyl, ethyl, propyl, butyl, isopropyl, tert-butyl and isobutyl.

The term alkyl further includes alkyl groups which can further include oxygen, nitrogen, sulfur or phosphorous atoms replacing one or more carbons of the hydrocarbon backbone. In an embodiment, a straight chain or branched chain alkyl has 10 or fewer carbon atoms in its backbone (e.g., C]-C₁₀ for straight chain, C₃-C₁₀ for branched chain), and more preferably 6 or fewer carbons. Likewise, preferred cycloalkyls have from 4-7 carbon atoms in their ring structure, and more preferably have 5 or 6 carbons in the ring structure. Moreover, alkyl (e.g., methyl, ethyl, propyl, butyl, pentyl, hexyl, etc.) includes both "unsubstituted alkyl" and "substituted alkyl", the latter of which refers to alkyl moieties having substituents replacing a hydrogen on one or more carbons of the hydrocarbon backbone, which allow the molecule to perform its intended function. The term "substituted" is intended to describe moieties having substituents replacing a hydrogen on one or more atoms, e.g. C, O or N, of a molecule. Such substituents can include, for example, alkenyl, alkynyl, halogen, hydroxyl, alkylcarbonyloxy, arylcarbonyloxy, alkoxycarbonyloxy, aryloxycarbonyloxy, carboxylate, alkylcarbonyl, arylcarbonyl, alkoxycarbonyl, aminocarbonyl, alkylaminocarbonyl, dialkylaminocarbonyl, alkylthiocarbonyl, alkoxyl, phosphate, phosphonato, phosphinato, amino (including alkyl amino, dialkylamino, arylamino, diarylamino, and alkylarylamino), acylamino (including alkylcarbonylamino, arylcarbonylamino, carbamoyl and ureido), amidino, imino, sulfhydryl, alkylthio, arylthio, thiocarboxylate, sulfates, alkylsulfinyl, sulfonato, sulfamoyl, sulfonamido, nitro, trifluoromethyl, cyano, azido, heterocyclic, alkylaryl, morpholino, phenol, benzyl, phenyl, piperizine, cyclopentane, cyclohexane, pyridine, 5H-tetrazole, triazole, piperidine, or an aromatic or heteroaromatic moiety.

Further examples of substituents of the invention, which are not intended to be limiting, include moieties selected from straight or branched alkyl (preferably Ci-C₅), cycloalkyl (preferably C₃-C₈), alkoxy (preferably Cj-C₆), thioalkyl (preferably Ci-C₆), alkenyl (preferably C₂-C₆), alkynyl (preferably C₂-C₆), heterocyclic, carbocyclic, aryl (e.g., phenyl), aryloxy (e.g., phenoxy), aralkyl (e.g., benzyl), aryloxyalkyl (e.g., phenyloxyalkyl), arylacetamidoyl, alkylaryl, heteroaralkyl, alkylcarbonyl and arylcarbonyl or other such acyl group, heteroarylcarbonyl, or heteroaryl group, (CR'R")o_-3NR'R" (e.g., -NH₂), (CR'R")_0-3CN (e.g., -CN), -NO₂, halogen (e.g., -F, -Cl, -Br, or -I), (CR'R")_0-3C(halogen)₃ (e.g. , -CF₃), (CR'R")_0-3CH(halogen)₂,

(CR'R")_0-3CH₂(halogen), (CR'R")_0-3CONR'R", (CR'R")_0-3(CNH)NR'R", (CR'R")o_ ₃S(O),.₂NR'R", (CR'R")_0-3CHO, (CR'R")₀.₃O(CR'R")_0-3H, (CR' R")_0-3 S(O)_0-3R' (e.g., -SO₃H, -OSO₃H), (CR'R")_0-3O(CR'R")_0-3H (e.g., -CH₂OCH₃ and -OCH₃), (CR'R")_o-3S(CR'R")o_-3H (e.g., -SH and -SCH₃), (CR'R")o-₃OH (e.g., -OH), (CR'R")_0-3COR', (CR'R")_0-3(substituted or unsubstituted phenyl), (CR'R")_0-3(C₃-C₈ cycloalkyl), (CR'R")_0-3CO₂R' (e.g., -CO₂H), or (CR'R")_0-3OR' group, or the side chain of any naturally occurring amino acid; wherein R' and R" are each independently hydrogen, a Cj-C₅ alkyl, C₂-C₅ alkenyl, C₂-C₅ alkynyl, or aryl group. Such substituents can include, for example, halogen, hydroxyl, alkylcarbonyloxy, arylcarbonyloxy, alkoxycarbonyloxy, aryloxycarbonyloxy, carboxylate, alkylcarbonyl, alkoxycarbonyl, aminocarbonyl, alkylthiocarbonyl, alkoxyl, phosphate, phosphonato, phosphinato, cyano, amino (including alkyl amino, dialkylamino, arylamino, diarylamino, and alkylarylamino), acylamino (including alkylcarbonylamino, arylcarbonylamino, carbamoyl and ureido), amidino, imino, oxime, thiol, alkylthio, arylthio, thiocarboxylate, sulfates, sulfonato, sulfamoyl, sulfonamido, nitro, trifluoromethyl, cyano, azido, heterocyclyl, or an aromatic or heteroaromatic moiety. In certain embodiments, a carbonyl moiety (C=O) can be further derivatized with an oxime moiety, e.g., an aldehyde moiety can be derivatized as its oxime (-C=N-OH) analog. It will be understood by those skilled in the art that the moieties substituted on the hydrocarbon chain can themselves be substituted, if appropriate. Cycloalkyls can be further substituted, e.g., with the substituents described above. An "aralkyl" moiety is an alkyl substituted with an aryl (e.g., phenylmethyl (i.e., benzyl)). The term "amine" or "amino" should be understood as being broadly applied to both a molecule, or a moiety or functional group, as generally understood in the art, and can be primary, secondary, or tertiary. The term "amine" or "amino" includes compounds where a nitrogen atom is covalently bonded to at least one carbon, hydrogen or heteroatom. The terms include, for example, but are not limited to, "alkyl amino," "arylamino," "diarylamino," "alkylarylamino," "alkylaminoaryl," "arylaminoalkyl," "alkaminoalkyl," "amide," "amido," and "aminocarbonyl." The term "alkyl amino" comprises groups and compounds wherein the nitrogen is bound to at least one additional alkyl group. The term "dialkyl amino" includes groups wherein the nitrogen atom is bound to at least two additional alkyl groups. The term "arylamino" and "diarylamino" include groups wherein the nitrogen is bound to at least one or two aryl groups, respectively. The term "alkylarylamino," "alkylaminoaryl" or "arylaminoalkyl" refers to an amino group which is bound to at least one alkyl group and at least one aryl group. The term "alkaminoalkyl" refers to an alkyl, alkenyl, or alkynyl group bound to a nitrogen atom which is also bound to an alkyl group.

The term "amide," "amido" or "aminocarbonyl" includes compounds or moieties which contain a nitrogen atom which is bound to the carbon of a carbonyl or a thiocarbonyl group. The term includes "alkaminocarbonyl" or "alkylaminocarbonyl" groups which include alkyl, alkenyl, aryl or alkynyl groups bound to an amino group bound to a carbonyl group. It includes arylaminocarbonyl and arylcarbonylamino groups which include aryl or heteroaryl moieties bound to an amino group which is bound to the carbon of a carbonyl or thiocarbonyl group. The terms "alkylaminocarbonyl," "alkenylaminocarbonyl," "alkynylaminocarbonyl," "arylaminocarbonyl," "alkylcarbonylamino," "alkenylcarbonylamino," "alkynylcarbonylamino," and "arylcarbonylamino" are included in term "amide." Amides also include urea groups (aminocarbonylamino) and carbamates (oxycarbonylamino). The term "aryl" includes groups, including 5- and 6-membered single-ring aromatic groups, that can include from zero to four heteroatoms, for example, phenyl, pyrrole, furan, thiophene, thiazole, isothiaozole, imidazole, triazole, tetrazole, pyrazole, oxazole, isoxazole, pyridine, pyrazine, pyridazine, and pyrimidine, and the like. Furthermore, the term "aryl" includes multicyclic aryl groups, e.g., tricyclic, bicyclic, e.g., naphthalene, benzoxazole, benzodioxazole, benzothiazole, benzoimidazole, benzothiophene, methylenedioxyphenyl, quinoline, isoquinoline, anthryl, phenanthryl, napthridine, indole, benzofuran, purine, benzofuran, deazapurine, or indolizine. Those aryl groups having heteroatoms in the ring structure can also be referred to as "aryl heterocycles", "heterocycles," "heteroaryls" or "heteroaromatics." The aromatic ring can be substituted at one or more ring positions with such substituents as described above, as for example, alkyl, halogen, hydroxyl, alkoxy, alkylcarbonyloxy, arylcarbonyloxy, alkoxycarbonyloxy, aryloxycarbonyloxy, carboxylate, alkylcarbonyl, alkylaminoacarbonyl, aralkylaminocarbonyl, alkenylaminocarbonyl, alkylcarbonyl, arylcarbonyl, aralkylcarbonyl, alkenylcarbonyl, alkoxycarbonyl, aminocarbonyl, alkylthiocarbonyl, phosphate, phosphonato, phosphinato, cyano, amino (including alkyl amino, dialkylamino, arylamino, diarylamino, and alkylarylamino), acylamino (including alkylcarbonylamino, arylcarbonylamino, carbamoyl and ureido), amidino, imino, sulfhydryl, alkylthio, arylthio, thiocarboxylate, sulfates, alkylsulfinyl, sulfonato, sulfamoyl, sulfonamido, nitro, trifluoromethyl, cyano, azido, heterocyclyl, alkylaryl, or an aromatic or heteroaromatic moiety. Aryl groups can also be fused or bridged with alicyclic or heterocyclic rings which are not aromatic so as to form a polycycle (e.g., tetralin). The term "treated," "treating" or "treatment" includes the diminishment or alleviation of at least one symptom associated with the condition being treated. For example, treatment can be diminishment of one or several symptoms of a disorder or complete eradication of a disorder, such as tumors, particularly gliomas and glioblastoma multiforme (GBM). As used herein, the phrase "therapeutically effective amount" of the compound is the amount necessary or sufficient to treat or prevent the condition being treated. In an example, an effective amount of the compound is the amount sufficient to alleviate tumors, particularly gliomas and glioblastoma multiforme (GBM), in a subject.

The term "subject" is intended to include animals, which are capable of suffering from or afflicted with tumors, particularly gliomas and glioblastoma multiforme (GBM). Examples of subjects include mammals, e.g., humans, dogs, cows, horses, pigs, sheep, goats, cats, mice, rabbits, rats, and transgenic non-human animals. In certain embodiments, the subject is a human, e.g., a human suffering from, at risk of suffering from, or potentially capable of suffering from tumors, particularly gliomas and glioblastoma multiforme (GBM).

Compositions of the Invention

The present invention relates to the use of the combination of a growth factor receptor inhibitor with a compound that inhibits the binding of the second mitochondria- derived activator of caspase (Smac) protein to inhibitor of apoptosis (IAPs) (IAP inhibitor), and one or more pharmaceutically active agents; pharmaceutical compositions comprising said combination; and a commercial package comprising said combination. The present invention also relates to the use of growth factor receptor inhibitors with IAP inhibitors in combination with one or more pharmaceutically active agents for the preparation of a medicament to treat tumors, particularly gliomas and glioblastoma multiforme (GBM).

In one embodiment, the present invention also relates to the use of a pharamaceutical composition comprising a growth factor receptor inhibitor and N-[I- cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2- methylamino-propionamide for the treatment of tumors, particularly gliomas and glioblastoma multiforme (GBM). In another embodiment, the present invention also relates to a pharmaceutical composition comprising a growth factor receptor inhibitor and (S)-N-((S)- 1 -cyclohexyl-2- { (5)-2- [4-(4-fluoro-benzoyl)-thiazol-2-yl]-pyrrolidin- 1 - yl}-2-oxo-ethyl)-2-methylamino-propionamide for the treatment of tumors, particularly gliomas and glioblastoma multiforme (GBM).

In one embodiment, the present invention also relates to the use of a growth factor inhibitor in combination with one or more IAP inhibitors for the preparation of a medicament to treat tumors, including gliomas and glioblastomas.

In an embodiment, the growth factor inhibitor is selected from one of: i) a platelet-derived growth factor (PDGF) receptor tyrosine kinase inhibitor; ii) a human epidermal growth factor type 1 /epidermal growth factor receptor (HERl /EGFR) inhibitor; iii) epidermal growth factor (EGF) receptor protein tyrosine kinase inhibitor; iv) inhibitors of the insulin-like Growth Factor I Receptor; and v) combinations thereof.

In an embodiment, the present invention includes a pharmaceutical composition comprising a combination comprising a growth factor receptor inhibitor with an IAP inhibitor, optionally together with a pharmaceutical carrier.

In another embodiment, the pharmaceutical composition of the present invention includes a compound of formula I, which is N-[I -cyclohexyl-2-oxo-2-(6-phenethyl- octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2-methylamino-propionamide.

In yet another embodiment, the pharmaceutical composition of the present invention includes a compound of formula I, which is (S)-N-((S)-\ -cyclohexyl-2- {(S)-2- [4-(4-fluoro-benzoyl)-thiazol-2-yl] -pyrrolidin- 1 -yl } -2-oxo-ethyl)-2-methylamino- propionamide.

In an embodiment, the present invention is a pharmaceutical composition for the treatment of gliomas. In another embodiment, the present invention includes a commercial package comprising a combination of a compound of formula I and III useful in glioma treatment, together with instructions for simultaneous, separate or sequential use thereof in the treatment of gliomas.

In another embodiment, the present invention includes a commercial package comprising a combination of a compound of formula I and IV useful in glioma treatment, together with instructions for simultaneous, separate or sequential use thereof in the treatment of gliomas.

In yet another embodiment, the present invention includes the use of a combination of a compound of formula I and III for the preparation of a medicament for the treatment of gliomas. In another embodiment, the present invention includes the use of a combination of a compound of formula I and IV for the preparation of a medicament for the treatment of gliomas.

The present invention further includes a combination comprising a therapeutically effective amount of a growth factor receptor inhibitor with an IAP inhibitor. The present invention further includes a combination wherein the compound of formula I is 7V-[l-cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin- l-yl)-ethyl]-2-methylamino-propionamide. The present invention further includes a combination wherein the compound of formula I is (5)-iV-((5)-l-cyclohexyl-2-{(5)-2-[4- (4-fluoro-benzoyl)-thiazol-2-yl]-pyrrolidin-l-yl}-2-oxo-ethyl)-2-methylamino- propionamide.

Examples of IAP inhibitors for use in the present invention include compounds according to formula I:

and pharmaceutically acceptable salts, enantiomers, stereoisomers, rotamers, tautomers, diastereomers, or racemates thereof; wherein

Ri is H; Ci-C₄alkyl; d-C₄alkenyl; Q-C₄alkynyl or C₃-C₁₀cycloalkyl which are unsubstituted or substituted;

R₂ is H; Ci-C₄alkyl; Cj-C₄alkenyl; Ci-C₄alkynyl or C₃-C₁₀cycloalkyl which are unsubstituted or substituted;

R₃ is H; -CF₃; -C₂F₅; C_rC₄alkyl; CrC₄alkenyl; d-C₄alkynyl; -CH₂-Z, or

R₂ and R₃, together with the nitrogen, form a het ring;

Z is H; -OH; F; Cl; -CH₃; -CF₃; -CH₂Cl; -CH₂F or -CH₂OH; R₄ is CrCi_δStraight or branched alkyl; Ci-Ci₆alkenyl; Ci-Ci₆alkynyl; or -C₃- Ciocycloalkyl; -(CH₂)i_-6-Zj; -(CH₂)_0-6-arylphenyl; and -(CH₂)_0-6-het, wherein alkyl, cycloalkyl and phenyl are unsubstituted or substituted;

Zi is -N(R₈)-C(O)-C₁-C₁₀alkyl; -N(R₈)-C(O)-(CH₂)i_-6-C₃-C₇cycloalkyl; -N(R₈)- C(O)-(CH₂)_0-6-phenyl; -N(R₈)-C(O)-(CH₂)i_-6-het; -C(O)-N(R₉)(Ri₀); -C(O)-O-C₁-

C₁₀alkyl; -C(O)-O-(CH₂)i_-6-C₃-C₇cycloalkyl; -C(O)-O-(CH₂)_0-6-phenyl; -C(O)-O-(CH₂) i. ₆-het; -O-C(O)-C₁-C₁₀alkyl; -O-C(O)-(CH₂)_1-6-C₃-C₇cycloalkyl; -O-C(O)-(CH₂)_0-6- phenyl; -0-C(O)-(CH₂) i-₆-het, wherein alkyl, cycloalkyl and phenyl are unsubstituted or substituted; het is a 5- to 7-membered heterocyclic ring containing 1-4 heteroatoms selected from N, O and S, or an 8- to 12-membered fused ring system including at least one 5- to 7-membered heterocyclic ring containing 1 , 2 or 3 heteroatoms selected from N, O and S, which heterocyclic ring or fused ring system is unsubstituted or substituted on a carbon or nitrogen atom; R₈ is H; -CH₃; -CF₃; -CH₂OH or -CH₂Cl;

R₉ and R₁₀ are each independently H; Ci-C₄alkyl; C₃-C₇cycloalkyl; -(CH₂)_I-6-C₃- C₇cycloalkyl; -(CH₂)_0-6-phenyl, wherein alkyl, cycloalkyl and phenyl are unsubstituted or substituted, or

R₉ and R₁₀, together with the nitrogen, form het; R₅ is H; Ci-C₁₀alkyl; aryl; phenyl; C₃-C₇cycloalkyl; -(CH₂)i_-6-C₃-C₇cycloalkyl; -

C,-Ci₀alkyl-aryl; -(CH₂)_0-6-C₃-C₇cycloalkyl-(CH₂)_0-6-phenyl; -(CH₂)_0-4CH-((CH₂)_1-4- phenyl)₂; -(CH₂)_0-6-CH(phenyl)₂; -indanyl; -C(O)-Ci-Ci₀alkyl; -C(O)-(CH₂)_1-6-C₃- C₇cycloalkyl; -C(O)-(CH₂)_0-6-phenyl; -(CH₂)_0-6-C(O)-phenyl; -(CH₂)_0-6-het; -C(O)- (CH₂)i_-6-het, or R₅ is a residue of an amino acid, wherein the alkyl, cycloalkyl, phenyl and aryl substituents are unsubstituted or substituted;

U is as shown in structure II:

wherein n = 0-5; X is -CH or N;

Ra and Rb are independently an O, S or N atom or Co-C₈alkyl, wherein one or more of the carbon atoms in the alkyl chain may be replaced by a heteroatom selected from O, S or N, and where the alkyl may be unsubstituted or substituted;

Rd is selected from:

(a) -Re-Q- (Rf)_p(Rg)_q; or

(b) Ar,-D-Ar₂; or (c) Ar₁-D-;

Rc is H or Rc and Rd may together form a cycloalkyl or het; where if Rd and Rc form a cycloalkyl or het, R₅ is attached to the formed ring at a C or N atom; p and q are independently 0 or 1 ;

Re is Ci.C₈alkyl or alkylidene, and Re may be unsubstituted or substituted; Q is N, O, S, S(O) or S(O)₂;

Ari and Ar₂ are substituted or unsubstituted aryl or het;

Rf and Rg are each independently none, or H; -Ci-Cioalkyl; Cj-Cioalkylaryl; - OH; -O-Ci-Cioalkyl; -(CH₂)_0-6-C₃-C₇cycloalkyl; -O-(CH₂)_0-6-aryl; phenyl; aryl; phenyl- phenyl; -(CH₂)_1-6-het; -O-(CH₂)i-₆-het; -OR₁₁; -C(O)-R₁₁; -C(O)-N(R₁₁)(R₁₂); -N(R₁₁)(R₁₂); -S-R₁₁; -S(O)-R₁₁; -S(O)₂-R₁₁; -S(O)₂-NR₁₁R₁₂; -NR₁₁-S(O)₂- R₁₂; S-C₁- C₁₀alkyl; aryl-Ci-C₄alkyl; het-Ci-C₄alkyl, wherein alkyl, cycloalkyl, het and aryl are unsubstituted or substituted; -SO_2-C _!.C₂alkyl; -SO_2-C_1-C₂alkylphenyl; -O-Ci-C₄alkyl, or

Rg and Rf form a ring selected from het or aryl; and

D is -CO-; -C(O)- or Ci.C₇alkylene or arylene; -CF₂-; -0-; -or S(O)₁₁₁, where rn is 0-2; l,3dioaxolane; or Ci.C₇alkyl-OH, where alkyl, alkylene or arylene may be unsubstituted or substituted with one or more halogens, OH, -O-C_!-C₆alkyl, -S-Cj- C₆alkyl or -CF₃, or

D is -N(Rh), wherein Rh is H; Ci-C₇alkyl (unsubstituted or substituted); aryl; - O(C|.C₇cycloalkyl) (unsubstituted or substituted); C(O)-Ci -C i_Oalkyl; C(O)-C₀-C ₁₀alkyl- aryl; C-O-Ci-C,₀alkyl; C-O-C₀-C ₁₀alkyl-aryl; SO₂-Ci₀-Ci₀-alkyl; or SO₂-(Co-Ci₀- alkylaryl); R<₃, R₇, R'₆ and R'₇ are each independently H; -Ci-C]_Oalkyl; -d-Cioalkoxy; aryl- C₁-C_1OaIkOXy; -OH; -O-Q-Cioalkyl; -(CH₂)_0-6-C₃-C₇cycloalkyl; -O-(CH₂)_0-6-aryl; phenyl; -(CH₂) _1-6-het; -O-(CH₂)i_-6-het; -OR₁₁; -C(O)-R₁₁; -C(O)-N(R₁₁)(Ri₂); - N(R_n)(R₁₂); -S-R_n; -S(O)-Rn; -S(O)₂-R₁₁; -S(O)₂-NR₁₁Ri₂; -NR₁₁-S(O)₂- Rj₂, wherein alkyl, cycloalkyl and aryl are unsubstituted or substituted; and R₆, R₇, R' ₆ and R'₇ can be united to form a ring system; and

Rn and Rn are independently H; Ci-Ci_Oalkyl; -(CH₂)o-₆-C₃-C₇cycloalkyl; - (CH₂)(w-(CH)_w(aryl)i-₂; -C(O)-d-C₁₀alkyl; -C(O)-(CH₂)_1-6-C₃-C₇cycloalkyl; -C(O)-O- (CH₂)o_-6-aryl; -C(O)-(CH₂)_0-6-O-fluorenyl; -C(O)-NH-(CH₂)_0-6-aryl; -C(O)-(CH₂)₀-₆-aryl; -C(O)-(CH₂)_1-6-het; -C(S)-C₁-C₁₀alkyl; -C(S)-(CH₂)_1-6-C₃-C₇cycloalkyl; -C(S)-O-(CH₂)_0- ₆-aryl; -C(S)-(CH₂)_0-6-O-fluorenyl; -C(S)-NH-(CH₂)_0-6-aryl; -C(S)-(CH₂)_0-6-aryl; -C(S)- (CH₂) i.₆-het, wherein alkyl, cycloalkyl and aryl are unsubstituted or substituted, or

Rn and Rj₂ are a substituent that facilitates transport of the molecule across a cell membrane, or R₁₁ and Ri₂, together with the nitrogen atom, form het, wherein the alkyl substituents of Rn and Ri₂ may be unsubstituted or substituted by one or more substituents selected from Ci-Ci_Oalkyl, halogen, OH, -O-Ci-C₆alkyl, -S- Ci-C₆alkyl or -CF₃; substituted cycloalkyl substituents of Rn and R]₂ are substituted by one or more substituents selected from a Ci-Ci₀ alkene; Ci-C₆alkyl; halogen; OH; -O-Ci-C₆alkyl; -S- d-Qalkyl or -CF₃; and substituted phenyl or aryl of Rn and R₁₂ are substituted by one or more substituents selected from halogen; hydroxy; C_!-C₄alkyl; Ci-C₄alkoxy; nitro; -CN; -O- C(O)-C i-C₄alkyl and -C(O)-O-C i-C₄aryl. In one embodiment of formula I, Rj, R₂, and R₃ are each, independently, H or

Ci-C₄alkyl. In another embodiment of formula II, R₄ is C₃-Ci₀cycloalkyl.

In one embodiment of formula I, U-R₅ is

wherein Ar is substituted or unsubstituted aryl or het. In another embodiment of formula I, U-R₅ is

wherein m is 0, 1, 2, or 3, and Ar is substituted or unsubstituted aryl or het.

Examples of other IAP inhibitors include compounds disclosed in WO 05/097791 published on October 20, 2005, which is hereby incorporated into the present application by reference. Preferred compounds within the scope of formula I are N-[I- cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2- methylamino-propionamide and (S)-N-((S)- 1 -cyclohexyl-2- {(5)-2-[4-(4-fluoro-benzoyl)- thiazol-2-yl]-pyrrolidin-l-yl}-2-oxo-ethyl)-2-methylamino-propionamide. The preferred IAP inhibitors are selected from the group consisting of (S)-N- [(S)-

1 -Cyclohexyl-2-oxo-2-(.S)-(6-phenethyl-octahydro-pyrrolo [2,3 -c]pyridin- 1 -yl)-ethyl] -2- methylamino-propionamide; (5)-N-((5)-l-Cyclohexyl-2-{(5)-2-[4-(4-fluoro-benzoyl)- thiazol-2-yl]-pyrrolidin-l-yl}-2-oxo-ethyl)-2-methylamino-propionamide; (S)-N-[(S)- Cyclohexyl-(ethyl- { (S)- 1 - [5-(4-fluoro-benzoyl)-pyridin-3 -yl] -propyl } carbamoyl)- methyl]-2-methylamino-propionamide; (5)-N-((5)-l-Cyclohexyl-2-{(5)-2-[5-(4-fluoro- phenoxy)-pyridin-3-yl]-pyrrolidin-l-yl}-2-oxo-ethyl)-2-methylamino-propionamide; and N-[I -Cyclohexyl-2-(2-{2-[(4-fluorophenyl)-methyl-amino]-pyridin-4-yl}pyrrolidin- l-yl)-2-oxo-ethyl]-2-methylamino-propinamide; and pharmaceutically acceptable salts thereof Additional IAP inhibitors include compounds disclosed in WO 04/005284,

PCT/US2006/013984 and PCT/US2006/021850. Other IAP inhibitor compounds for use in the present invention include those disclosed in WO 06/069063, WO 05/069888, US2006/0014700, WO 04/007529, US2006/0025347, WO 06/010118, WO 05/069894, WO 06/017295, WO 04/007529 and WO 05/094818. Comprised are likewise the pharmaceutically acceptable salts thereof, the corresponding racemates, diastereoisomers, enantiomers, tautomers, as well as the corresponding crystal modifications of above disclosed compounds where present, e.g., solvates, hydrates and polymorphs, which are disclosed therein.

The precise dosage of an IAP inhibitor compound to be employed depends upon several factors including the host, the nature and the severity of the condition being treated, the mode of administration. The IAP inhibitor compound can be administered by any route including orally, parenterally, e.g., intraperitoneally, intravenously, intramuscularly, subcutaneously, intratumorally, or rectally, or enterally. Preferably, the

IAP inhibitor compound is administered orally, preferably at a daily dosage of 1-300 mg/kg body weight or, for most larger primates, a daily dosage of 50-5,000, preferably

500-3,000 mg. A preferred oral daily dosage is 1-75 mg/kg body weight or, for most larger primates, a daily dosage of 10-2,000 mg, administered as a single dose or divided into multiple doses, such as twice daily dosing.

Usually, a small dose is administered initially and the dosage is gradually increased until the optimal dosage for the host under treatment is determined. The upper limit of dosage is that imposed by side effects and can be determined by trial for the host being treated.

Dosage regimens must be titrated to the particular indication, the age, weight and general physical condition of the patient, and the response desired but generally doses will be from about 10 mg/day to about 500 mg/day as needed in single or multiple daily administration.

The growth factor receptor inhibitor may be selected from: i) a platelet-derived growth factor (PDGF) receptor tyrosine kinase inhibitor, such as imatinib or nilotinib, ii) a human epidermal growth factor type 1 /epidermal growth factor receptor (HERl /EGFR) inhibitor, such as erlotinib, iii) epidermal growth factor (EGF) receptor protein tyrosine kinase inhibitor, iv) inhibitors of the insulin-like Growth Factor I

Receptor, and v) combinations thereof.

In an embodiment, the PDGF inhibitor may be 4-methyl-3-[[4-(3-pyridinyl)-2- pyrimidinyl]amino]-N-[5-(4-methyl-lH-imidazol-l-yl)-3-(trifluoromethyl)phenyl] benzamide, and pharmaceutically acceptable salts thereof, of the formula III, which is also known as nilotinib, and is disclosed, along with the process for its manufacture in

WO 04/005281 published on January 15, 2004 which is hereby incorporated into the present application by reference:

Combinations of the present invention may include the compound 4-(4-methylpiperazin- 1 -ylmethyl)-N- [4-methyl-3 -(4-pyridin-3 -yl)pyrimidin-2- ylamino)phenyl]-benzamide (Imatinib, which is sold under the name Gleevec®) is of the formula IV:

The preparation of Compound IV and the use thereof, especially as an anti- tumour agent, are described in Example 21 of European patent application EP-A-O 564 409, which was published on 6 October 1993, and in equivalent applications and patents in numerous other countries, e.g. in US patent 5,521,184 and in Japanese patent 2706682.

The monomethanesulfonic acid addition salt of Compound IV and a preferred crystal form thereof are described in PCT patent application WO99/03854 published on January 28, 1999. The EGFR inhibitors may be a compound such as erlotinib, which is 4- aminopyrazole [3,4-d] pyrimidine and 4-aminopyrazole [3,4-d] pyridine compounds as disclosed in U.S. Patent No. 5,593,997, herein incorporated by reference.

The EGF receptor tyrosine kinase inhibitor may be 7H-pyrrolo[2,3-d]pyrimidine derivatives of formula V:

wherein q' is O or 1, n' is from 1 to 3 when q' is 0, or n' is from 0 to 3 when q' is 1 ,

R^E is halogen, lower alkyl, hydroxy, lower alkanoyloxy, lower alkoxy, carboxy, lower alkoxycarbonyl, carbamoyl, N-lower alkyl-carbamoyl, N,N-di- lower alkyl-carbamoyl, cyano, amino, lower alkanoylamino, lower alkylamino, N,N-di-lower alkylamino or trifluoromethyl, it being possible when several radicals R^E are present in the molecule for those radicals to be identical or different, a) R^Ei and R^E ₂ are each independently of the other phenyl substituted by carbamoyl-methoxy, carboxy-methoxy, benzyloxycarbonyl-methoxy, lower alkoxycarbonyl-methoxy, phenyl, amino, lower alkanoylamino, lower alkylamino, N,N-di-lower alkylamino, hydroxy, lower alkanoyloxy, carboxy, lower alkoxycarbonyl, carbamoyl, N-lower alkyl-carbamoyl, N,N-di-lower alkyl- carbamoyl, cyano or by nitro; hydrogen under the proviso that R^E _! and R^E ₂ cannot represent hydrogen at the same time; unsubstituted or halo- or lower alkyl-substituted pyridyl;

N-benzyl-pyridinium-2-yl; naphthyl; cyano; carboxy; lower alkoxycarbonyl; carbamoyl; N-lower alkyl-carbamoyl; N,N-di-lower alkyl- carbamoyl; N-benzyl-carbamoyl; formyl; lower alkanoyl; lower alkenyl; lower alkenyloxy; or lower alkyl substituted by halogen, amino, lower alkylamino, piperazino, di-lower alkylamino, phenylamino that is unsubstituted or substituted in the phenyl moiety by halogen, lower alkyl, hydroxy, lower alkanoyloxy, lower alkoxy, carboxy, lower alkoxycarbonyl, carbamoyl, N-lower alkyl-carbamoyl, N,N-di- lower alkyl-carbamoyl, cyano, amino, lower alkanoylamino, lower alkylamino, N,N-di-lower alkylamino or by trifluoromethyl, hydroxy, lower alkoxy, cyano, carboxy, lower alkoxycarbonyl, carbamoyl, N-lower alkyl-carbamoyl, N,N-di- lower alkyl-carbamoyl, mercapto or by a radical of the formula R^E ₃-S(O)_m'- wherein R^E ₃ is lower alkyl and m' is 0, 1 or 2, or b) when q' is 0, one of the radicals R^E! and R ₂ is unsubstituted lower alkyl or unsubstituted phenyl and the other of the radicals R^E! and R^E ₂ has one of the meanings given above in paragraph a) with the exception of hydrogen, or c) when q' is 1, R^E _! and R^E ₂ are each independently of the other unsubstituted phenyl or have one of the meanings given above in paragraph a), and

R^E ₆ is hydrogen, lower alkyl, lower alkoxycarbonyl, carbamoyl, N-lower alkyl-carbamoyl or N,N-di-lower alkyl-carbamoyl, and to the salts thereof.

The radicals and symbols as used in the definition of a compound of formula V have the meanings as disclosed in WO 97/02266 which publication is hereby incorporated into the present application by reference.

In another preferred embodiment of the invention, a compound of formula

V is employed wherein q' is 1, n' is 0, R^E] is hydrogen, R^E ₂ is phenyl substituted by hydroxy, and R^E ₆ is methyl. In a further preferred embodiment of the invention, a compound of formula

V is employed wherein q' is 1, n' is 0, R^E _! is hydrogen, R^E ₂ is phenyl substituted by CH₃-CH₂-CO-NH-, and R^E ₆ is methyl.

Compounds comprised of the pharmaceutical combination as a second active ingredient which inhibit the EGF receptor tyrosine kinase are furthermore in particular quinazoline derivatives of the formula VI:

wherein z is 1, 2 or 3 and each R^z ₂ is independently halogen, trifluoromethyl or C₁- C₄alkyl;

R^Z ₃ is Q^alkoxy; and R^Z _! is Ci-C₄alkoxy; di-(Ci-C₄alkyl)amino-C₂-C₄alkoxy, pyrrolidin-l-yl-C₂-

C₄alkoxy, piperidino-C₂-C₄alkoxy, moφholino-l-yl-C₂-C₄alkoxy, piperazin-1-yl- C₂-C₄alkoxy, 4-C_!-C₄alkylpiperazin- 1 -yl-C₂-C₄alkoxy, imidazol- 1 -yl-C₂- Qalkoxy, di-[(Ci-C₄alkoxy)-C₂-C₄alkyl]amino-C₂-C₄alkoxy, thiamorpholino-C₂- C₄alkoxy, 1 -oxothiamorpholino-C₂-C₄alkoxy or l,l-dioxothiamorpholino-C₂- C₄alkoxy, and wherein any of the above-mentioned R^z _\ substituents comprising a methylene group which is not attached to a N or O atom optionally bears on said methylene group a hydroxy substituent, or a pharmaceutically acceptable salt thereof. The radicals and symbols as used in the definition of a compound of formula VI have the meanings as disclosed in WO 96/33980 which publication is hereby incorporated into the present application by reference.

Preferably, a compound of formula VI is employed wherein R^zi and R^z ₃ are both methoxy and R^z ₂ is bromo or a pharmaceutically acceptable salt thereof. More preferably, a compound of formula VI is employed which is 4-(3'- chloro-4 ' -fluoroanilino)-7-methoxy-6-(3 -morpholinopropoxy)quinazoline or a pharmaceutically acceptable salt thereof.

The inhibitors of the insulin-like Growth Factor I Receptor may be a compound of formula VII

wherein

R^U _! is hydrogen, unsubstituted or substituted lower alkyl or halogen,

R^U ₂ is lower alkyl substituted by unsubstituted, mono- or disubstituted amino or by a heterocyclic radical; a radical

wherein R^u ₃ is unsubstituted or substituted lower alkyl, unsubstituted, mono- or disubstituted amino, a heterocyclic radical, or if Z is present is also free or etherifϊed hydroxy, Y is oxygen, sulfur or imino, and Z is either not present, lower alkyl or amino-lower alkyl; or a radical R^u ₄- sulfonylamino-lower alkyl, wherein R^u ₄ is unsubstituted or substituted lower alkyl, unsubstituted, mono- or disubstituted amino or phenyl optionally substituted by lower alkyl, lower alkoxy or nitro, and X^u is a heteroatom selected from oxygen, nitrogen and sulfur, . or a salt of the said compounds.

Where compounds of formula VII are mentioned, this is meant to include also the tautomers and N-oxides of the compounds of formula VII. Where the plural form is used for compounds, salts, and the like, this is taken to mean also a single compound, salt, or the like. Asymmetric carbon atoms of a compound of formula VII that are optionally present may exist in the (R), (S) or (R,S) configuration, preferably in the (R) or (S) configuration. Substituents at a double bond or a ring may be present in cis- (= Z-) or trans (= E-) form. The compounds may thus be present as mixtures of isomers or as pure isomers, preferably as enantiomer-pure diastereomers.

The term "a combined preparation", as used herein defines especially a "kit of parts" in the sense that the first and second active ingredient as defined above can be dosed independently or by use of different fixed combinations with distinguished amounts of the ingredients, i.e., simultaneously or at different time points. The parts of the kit of parts can then, e.g., be administered simultaneously or chronologically staggered, that is at different time points and with equal or different time intervals for any part of the kit of parts. Very preferably, the time intervals are chosen such that the effect on the treated disease in the combined use of the parts is larger than the effect which would be obtained by use of only any one of the active ingredients. The ratio of the total amounts of the active ingredient 1 to the active ingredient 2 to be administered in the combined preparation can be varied, e.g., in order to cope with the needs of a patient sub-population to be treated or the needs of the single patient which different needs can be due to age, sex, body weight, etc. of the patients. Preferably, there is at least one beneficial effect, e.g., a mutual enhancing of the effect of the first and second active ingredient, in particular a synergism, e.g. a more than additive effect, additional advantageous effects, less side effects, a combined therapeutical effect in a non-effective dosage of one or both of the first and second active ingredient, and especially a strong synergism the first and second active ingredient.

In particular, a therapeutically effective amount of each of the active ingredients of the combination of the invention may be administered simultaneously or sequentially and in any order, and the components may be administered separately or as a fixed combination. For example, the method of treatment of diseases according to the invention may comprise (i) administration of the first active ingredient in free or pharmaceutically acceptable salt form and (ii) administration of the second active ingredient in free or pharmaceutically acceptable salt form, simultaneously or sequentially in any order, in jointly therapeutically effective amounts, preferably in synergistically effective amounts, e.g. in daily dosages corresponding to the amounts described herein. The individual active ingredients of the combination of the invention can be administered separately at different times during the course of therapy or concurrently in divided or single combination forms. Furthermore, the term administering also encompasses the use of a pro-drug of an active ingredient that convert in vivo to the active ingredient. The instant invention is therefore to be understood as embracing all such regimes of simultaneous or alternating treatment and the term "administering" is to be interpreted accordingly. It will be understood that in the discussion of methods, references to the active ingredients are meant to also include the pharmaceutically acceptable salts. If these active ingredients have, for example, at least one basic center, they can form acid addition salts. Corresponding acid addition salts can also be formed having, if desired, an additionally present basic center. The active ingredients having an acid group (for example COOH) can also form salts with bases. The active ingredient or a pharmaceutically acceptable salt thereof may also be used in form of a hydrate or include other solvents used for crystallization.

The results disclosed herein indicate that a combination which comprises a combination of the invention achieves an improved therapeutic effect compared to either compound alone in the treatment of tumors, including gliomas and glioblastomas. One particular benefit of the combination of the invention is that lower doses of the active ingredients of the combination of the invention can be used, for example, that the dosages need not only often be smaller but are also applied less frequently, or can be used in order to diminish the incidence of side effects. This is in accordance with the desires and requirements of the patients to be treated.

The pharmacological activity of a combination of the invention may, for example, also be demonstrated in clinical studies. Such clinical studies are preferably randomized, double-blind, clinical studies in patients having tumors, such as gliomas and glioblastomas. Such studies demonstrate, in particular, the synergism of the active ingredients of the combination of the invention. The studies are, in particular, suitable to compare the effects of a monotherapy using the active ingredients and a combination of the invention.

The effective dosage of each of the active ingredients employed in the combination of the invention may vary depending on the particular compound or pharmaceutical composition employed, the mode of administration, the severity of the condition being treated. Thus, the dosage regimen the combination of the invention is selected in accordance with a variety of factors including the route of administration and the renal and hepatic function of the patient. A physician, clinician or veterinarian of ordinary skill can readily determine and prescribe the effective amount of the single active ingredients required to prevent, ameliorate or arrest the progress of the condition. Optimal precision in achieving concentration of the active ingredients within the range that yields efficacy without toxicity requires a regimen based on the kinetics of the active ingredients' availability to target sites. This involves a consideration of the distribution, equilibrium, and elimination of the active ingredients.

When the combination partners employed in the combination of the invention are applied in the form as marketed as single drugs for the indication pain, their dosage and mode of administration can take place in accordance with the information provided on the packet leaflet of the respective marketed drug in order to result in the beneficial effect described herein, if not mentioned herein otherwise.

Exemplification of the Invention The invention is further illustrated by the following examples, which should not be construed as further limiting. The animal models used throughout the examples are accepted animal models and the demonstration of efficacy in these animal models is predictive of efficacy in humans.

Combination ofLBW242 and Imatinib inhibits Glioma Cell Growth

The effects of the IAP inhibitor LBW242 (_V-[l-cyclohexyl-2-oxo-2-(6- phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2-methylamino-propionamide) on glioma cell proliferation were initially assessed using a MTS assay (Figure 1). The results of this analysis indicated that LBW242, at doses up to 5OuM, had no effect on the proliferation of U87 cells as a single agent. For all further experiments we used

LBW242 at a dosage of 50 uM as this tissue concentration is readily achievable in vivo. We next measured the effect of the combination of LBW242 and PDGFR inhibition with imatinib on tumor cell survival. The addition of LBW242 to imatinib therapy resulted in a significantly increased anti-tumor effect in both LN827 and U87 cells (Fig. 2A). Following four days of treatment (Fig. 2C), neither LBW242 or imatinib alone had a notable effect on tumor cell proliferation, however the combination treatment resulted in complete suppression of tumor cell growth. To further confirm that the synergy observed resulted from PDGFR inhibition, we next tested the combination of LB W242 with the potent PDGFR inhibitor AMN 107 (Nilotinib; Fig. 2D). A synergistic effect was again demonstrated, with the combination therapy resulting in reduced tumour cell proliferation.

To investigate the mechanism of synergy we assessed the phosphorylation status of PDGFR in LN827 cells. As shown in Figure 2B, increasing doses of imatinib resulted in a dramatic reduction in the level of phosphorylated PDGFR, whereas the amount of total PDGFR did not change significantly with drug treatment. The addition of LBW242 did not affect levels of either total or phosphorylated receptor. Furthermore, the inhibition of receptor phosphorylation corresponded to the dosages at which an anti- tumor effect was seen in the combination treatment arm (Fig. 2A). For example, an imatinib dose of 2.5 uM inhibited PDGFR phosphorylation, however an anti-tumor effect at that dose was only seen following addition of LB W242 (Fig 2A).

Imatinib triggers the apoptotic intrinsic pathway but only activates caspases in combination with LB W242.

To investigate the mechanism of synergy we next assessed the level of mitochondrial permeabilisation - a critical step in the apoptotic intrinsic pathway that occurs prior to caspase activation. Once the mitochondrial membrane has been breached, it releases pro-apoptotic factors into the cytosol, including cytochrome c and Smac/diablo. Therefore, we assessed the degree of mitochondrial permeabilisation by measuring the cytoplasmic levels of cytochrome c and Smac/diablo. The administration of imatinib alone led to a significant increase in both cytoplasmic cytochrome c and Smac/diablo, while LBW242 had no effect on cytochrome c or Smac/Diablo levels, either as a single agent or in combination with imatinib (Fig 3A). To further investigate the mechanism of action we next assessed the levels of caspase activity in U87 and LN827 cell lines. As shown in Figure 3B, the administration of neither imatinib nor LBW242 alone resulted in caspase activation. Combination of the two drugs resulted in synergistic increase in caspase 3 / 7 activity. Higher doses of imatinib resulted in increased caspase activity only when combined with LBW242 (Fig. 3B). Thus, imatinib treatment results in mitochondrial permeabilisation, but does not activate caspases unless IAP function is also inhibited.

To further confirm that the synergistic effect on tumor cell proliferation demonstrated with PDGFR and IAP inhibition is caused by an increase in apoptosis, we measured the number of apoptotic cells staining positive for Annexin-V (Figure 3C). PDGFR and IAP inhibition alone caused minimal change in basal apoptotic level, however the combination of imatinib and LBW242, as well as the combination of AMNl 07 and LBW242 resulted in the majority of tumor cells undergoing apoptosis. Growth factor inhibition and IAP inhibition activates caspases and suppresses tumor growth independent ofAkt

Next, we tested whether the phenomenon of growth factor inhibition plus IAP inhibition demonstrated with imatinib and LBW242 can be generalized to other growth factor pathways implicated in gliomagenesis. First, we assessed the combination of IGF-IR inhibition with IAP inhibition. AEW541 (see Cancer Cell. 2004 Mar;5(3):231- 9; incorporated herein by reference in its entirety) is a highly specific tyrosine kinase inhibitor that targets IGF-IR. The combination of AEW541 and LBW242 led to caspase 3/7 activation and synergistically inhibited tumor cell growth (Fig 4A). Next, we tested blockade of EGFR with the specific EGFR tyrosine kinase inhibitor PKI 166 (see Cancer Research 60, 2926-2935, June 1, 2000; Clinical Cancer Research Vol. 9, 1200-1210, March 2003; Cancer Research 63, 2940-2947, June 1, 2003; incorporated herein by reference in their entireties). PKI 166 as a single agent had a pro-apoptotic effect with increased levels of caspase 3/7 activation. However, the addition of IAP inhibition led to enhanced caspase 3/7 activation and a correlative increased inhibition of glioma cell proliferation (Figure 4B).

Because PDGFR, EGFR and IGF-IR all activate Akt, we next assessed whether the induction of apoptosis and inhibition of tumor growth demonstrated occur secondary to Akt inactivation. As shown in Figure 4D, Akt is tonically phosphorylated in LN827 cells. Administration of imatinib with or without LBW242 did not inhibit Akt phosphorylation, nor did it inhibit the downstream phosphorylation of Bad (Fig 4D). Furthermore, the combination of LBW242 and the specific Akt inhibitor triciribine, did not demonstrate any notable synergistic effect on either caspase 3/7 activation or tumor cell proliferation (Figure 4C). Thus the synergy between growth factor inhibition and IAP inhibition appears to occur independently of Akt status.

PDGFR inhibition synergises with IAP inhibition to suppress glioma growth in vivo.

Finally, we tested the combination of growth factor inhibition and IAP inhibition in an in vivo glioma model. Animals bearing established xenograft tumors with progressive growth during the postinjection period were separated into four groups. One group was treated with AMN 107 at 100 mg/kg per day, one group with LBW242 at 50 mg/kg twice a day, one group with vehicle and the fourth group with the combination of LBW242 and AMN 107. Tumor burden, as assessed by luminosity, was grossly diminished in combination treated animals compared with those treated with either agent alone or with vehicle (Fig. 5A). Growth curves derived from serial measurements of bioluminescence revealed that combination treatment resulted in complete cessation of tumor growth (Fig. 5B). The combination of two molecular targeted therapies - IAP inhibition with the small molecule LBW242 plus PDGFR inhibition - is synergistic, enhances apoptosis and suppresses tumor growth both in vitro and in vivo. Furthermore, the IAP inhibitor LBW242 can effectively be combined with inhibitors that target the other growth factor receptor tyrosine kinases EGFR and IGF-IR. These results are noteworthy for several reasons. Firstly, our results represent a novel approach to improve therapy with growth factor receptor inhibitors. While tyrosine kinase inhibitors hold great promise for improving outcomes, it is particularly unlikely that a single targeted therapy will ever form a definitive therapy in malignant gliomas, which are characterized by multiple altered tumorigenic pathways alongside widespread inter- and intra-tumoral heterogeneity. Indeed, despite the importance of growth factor pathways in glioma tumorigenesis, clinical responses to growth factor receptor inhibitors in glioma patients have been limited and, when present, often transient. Unlike CML, for example, which is primarily driven by a single genetic defect, and can effectively be treated by targeting that defect alone, in gliomas, targeted therapies and indeed conventional therapies, are confounded by the multitude of genetic abnormalities that act to thwart treatment efficacy.

We have shown an alteration in the apoptotic pathway reduces the effect of treatments targeting the growth factor pathways. That is, PDGFR inhibition alone results in activation of the intrinsic pathway and mitochondrial permeabilisation, but does not cause caspase activation or apoptosis, indicating a downstream block in the apoptotic cascade. It is only following the addition of IAP inhibition, that an increase in caspase activity results with subsequent apoptosis and an enhanced anti-tumor effect seen both in vitro and in vivo. Thus the strategy of targeting two separate molecular pathways - the aberrantly expressed IAPs in combination with the highly dysregulated growth factor pathway - effectively suppresses tumor growth.

Secondly, our results suggest that multiple factors need to be considered when evaluating responsiveness to growth factor receptor inhibitors. To date, most analyses have focused on receptor mutations and molecular pathways directly related to receptor signaling, such as PTEN status. For example, it has been shown that a clinical response to EGFR inhibition is more likely in tumours that express the EGFRvIII mutant in association with an intact PTEN signaling pathway. However, other studies have shown conflicting findings - in one report the response was associated with EGFR amplification and expression but not EGFRvIII. Our results suggest that distant downstream molecular abnormalities may be just as important in determining response to therapy both in the laboratory and in the clinic. Indeed, the IAPs represent one of the most downstream blockades to apoptosis and their successful inhibition illustrates the fact that targeting more distal pathways in combination with receptor tyrosine kinases may be at least as beneficial as focusing purely on local molecular events. Moreover, our results demonstrate a novel mechanism of bypassing molecular impediments to effective treatment. The synergy demonstrated appears to occur independent to, and without modulation of, Akt status. Both cell lines tested have mutations in the PTEN tumor suppressor gene, a factor not only associated with poor responses to growth factor receptor inhibitors, but also with an overall poor prognosis. By targeting the distal IAPs in combination with growth factor receptor inhibition, we have demonstrated a successful mechanism of bypassing the molecular PTEN/ Akt blockade.

Thirdly, the results here raise the prospect that similar strategies may be successfully applied to other tumors. A subset of ovarian cancer has been shown to over express PDGFR and to respond to treatment with imatinib. Our results raise the prospect that a similar strategy may be adopted to improve the response to PDGFR inhibition in cancers other than glioma.

Finally, this represents the first reported approach to targeting IAPs in gliomas that is readily translatable to the clinic. Previous preclinical studies validating IAPs as therapeutic targets in gliomas have utilized peptides, which in some cases were administered by direct intratumoral injection. While these innovative reports validated the notion of targeting IAPs, in terms of clinical translation, it is not feasible to use the peptides employed due to their instability and poor cellular permeability. The development of small molecule inhibitors of IAPs provides a more tractable method for clinical translation. To our knowledge ours is the first report of an effective small molecule IAP inhibitor in an in vivo glioma model. Moreover, the combination of PDGFR and IAP inhibition is readily translatable to the clinic as agents such as imatinib are readily available, with an established safety profile. In conclusion, IAP inhibition and growth factor inhibition induce apoptosis and suppress glioma growth both in vitro and in vivo. These results are readily translatable to clinical trial and offer the hope of improving treatment outcomes for patients with gliomas. The human glioma cell lines, U87 and LN827 were cultured in DMEM complete medium supplemented with 10% heat-inactivated fetal calf serum, penicillin (100 U/ml) and streptomycin (100 microg/ml). Cells were cultured in a humidified 10% CO₂ atmosphere at 37°C and maintained in a logarithmic growth phase for all experiments. LBW242, imatinib, AMN 107, AEW541 and PKI 166 were generously provided by Novartis Pharma. Triciribine was purchased from Calbiochem (San Diego, CA). Stock solutions of LBW242, AMNl 07, AEW541, PKIl 66 and triciribine were dissolved in dimethyl sulfoxide (DMSO) (Sigma- Aldrich, St Louis, MO) and stored at -20°C. Imatinib stock was dissolved in double distilled water and stored at — 20°C. All drugs were diluted in fresh medium immediately prior to use. Cell proliferation assays were performed with CellTiter 96 Aqueous One

Solution Cell Proliferation Assay (Promega Corp, Madison, WI) as per the manufacturer's recommendations. Briefly, 1 X 10³ cells were plated in 100 microliters of medium in 96 well microtiter plates and incubated for 24 hours. The indicated concentration of inhibitors was added, and the cells incubated for a further 48 to 72 hours. 20 microliters of labeling reagent was added to each well and allowed to incubate at 37° for 2 hours. The absorbance was then read at 490 nm with a 96-well plate reader.

Caspase 3/ 7 activity assays

Caspase 3 / 7 activity was measured with the Apo-One Homogenous Caspase-3/7 Assay kit (Promega Corp, Madison, WI) according to the manufacturer's protocol. Briefly, I X lO³ cells in 100 microliters of medium were plated in 96 well microtiter plates and incubated for 24 hours. The indicated concentration of inhibitors was added and the cells incubated for a further 48 hours. 100 microliters of labeling reagent was added to each well. Caspase 3/7 activity was measured after 6 hours incubation on a fluorescence plate reader with an excitation wavelength of 485 nm and emission wavelength of 535 nm. Flow Cytometric and Annexin V Analysis

2.5 x 10⁵ cells were plated in 60 mm plates in 2 mL of medium and cultured for 24 hours. Medium was removed and inhibitors were added in DMEM with 1% serum. Cells were cultured for a further 72 hours, collected for analysis, washed twice in cold PBS and resuspended in 100 microliters of binding buffer containing an Annexin V- FITC-propidium iodide mixture (Invitrogen, Eugene, Oregon) as per manufacturer's instructions. Before FACS analysis, an additional 400 microliters of binding buffer was added to the cell suspension. FACS analysis was performed on FACScan and gated to exclude cellular debris; 10,000 events were collected.

Antibodies and Western Blotting

Cells were pretreated with inhibitors, washed twice in ice-cold PBS, lysed with Radio Immuno Precipitation (RIPA) buffer (Boston Bioproducts, Worcester MA) containing 50 mM Tris-Cl (pH 7.4), 150 mM NaCl, 1% NP-40, 0.5% sodium deoxycholate, and 0.1% SDS with added 1 mM EDTA, 1 mM sodium orthovanadate, 50 mM NaF and Complete Protease Inhibitor cocktail (Roche Applied Science, Mannheim, Germany), vortexed for 5 seconds, and centrifuged at 14,000 rpm for 10 minutes at 4°C. Equal amounts of protein were loaded onto 4%-12% Bis-Tris-polyacrylamide gel (Invitrogen, Eugene, Oregon), separated by electrophoresis and transferred to nitrocellulose membranes (Invitrogen, Eugene, Oregon). Western blots were probed with β-actin (SigmarAldrich), PDGF Receptor Beta antibody (abeam, Cambridge, MA), and Phospho-PDGF Receptor Beta antibody, Phospho-Akt, Bad, and Phospho-Bad (all from Cell Signaling) as per manufacturer instructions. Blots were then labeled with anti-rabbit, or anti-mouse IgG-HRP antibody (Vector Laboratories, Burlingame, California) and visualized using enhanced chemiluminescence system (Amersham, Buckhinghamshire, England).

Immunoprecipitation studies

5 x 10⁵ cells were plated in 2 mL of medium in 60mm plates and incubated overnight. Medium was removed and the cells serum starved for 24 hours. Inhibitors were added for 90 minutes and the cells then stimulated with serum for 5 minutes. Cells were washed twice with ice-cold PBS and lysed with Radio Immuno Precipitation (RIPA) buffer (Boston Bioproducts, Worcester MA) containing 50 mM Tris-Cl (pH 7.4), 150 mM NaCl, 1% NP-40, 0.5% sodium deoxycholate, and 0.1% SDS with added 1 mM EDTA, 1 mM sodium orthovanadate, 50 mM NaF and Complete Protease Inhibitor cocktail (Roche Applied Science, Manheim, Germany). Standardized aliquots of lysate were incubated with PDGF Receptor Beta antibody (abeam, Cambridge, MA) overnight at 4°C, and immobilized on Protein G Sepharose (Amersham Biosciences, Uppsia, Sweden) for 1 hr. Beads were extensively washed with buffer. Samples were fractionated on SDS-PAGE, transferred to nitrocellulose, and immunoblotted with phospho-PDGF Beta receptor antibody (Cell Signaling) and PDGF Beta Receptor antibody (abeam, Cambridge, MA) as described above.

Mitochondrial permeabilisation analysis

5 x 10⁵ cells were seeded in each 6 cm plate and treated with drugs as indicated. Following 48 hours incubation, cells were collected and the mitochondria separated from cytoplasm using a mitochondria isolation kit (Pierce, Rockford, IL) as per manufacturer instructions. The cytosolic fraction was collected and equal amounts of protein were fractionated on SDS-PAGE, transferred to nitrocellulose, and immunoblotted with cytochrome c antibody (BD Pharmingen, USA), Smac/Diablo antibody (Cell signaling) and β-actin antibody (Sigma-Aldrich) as described above.

Tumor Cell Line Xenografts

Tumor cell lines were harvested in midlogarithmic growth phase and resuspended in PBS. Homozygous NCR nude mice (Charles River Laboratories) were anesthetized with ketamine hydrochloride at 150 mg/kg and xylazine at 12 mg/kg (Phoenix Pharmaceuticals, St. Joseph, MO) LP. A small surgical incision along midline was made to expose the calvarium and the periosteum was removed with a sterile, cotton swab. Mice were restrained in a stereotactic frame (Stoeltling) and a small burr-hole (size 34, Roboz, Gaithersburg, MD) was created at 2 mm lateral and 2 mm posterior to bregma. 50,000 LN827-LN cells in lOul PBS were injected through a 27-gauge needle over 3 minutes (3.3ul/min) at 3mm below the dura. The incision was closed with wound clips (Becton Dickenson, Cat. #427631) and removed 5-7 days after surgery. In vivo Treatment

Mice were imaged at least twice after implantation of cells to identify those in which tumor burden increased over time. Ten to 12 days after implantation of LN827- LN cells cohorts of 40 mice per experiment with approximately equivalent tumor bioluminescence were divided into equal control and treatment groups. Mice were treated with 50 mg/kg of LBW242 PO once daily and/or AMN 107 100mg/kg PO daily for 14 days.

In vivo Imaging Mice were anesthetized, injected with D-luciferin at 50 mg/ml i.p. (Xenogen,

Alameda, CA), and imaged with the IVIS Imaging System (Xenogen) for 10-120 s, bin size 2. To quantify bioluminescence, identical circular regions of interest were drawn to encircle the entire head of each animal, and the integrated flux of photons (photons per second) within each region of interest was determined by using the LIVING IMAGES software package (LI Version 2.50, Xenogen Corporation). Data were normalized to bioluminescence at the initiation of treatment for each animal.

Equivalents

Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments of the invention described herein. Such equivalents are intended to be encompassed by the following claims.

Incorporation by Reference The entire contents of all patents, published patent applications, websites, and other references cited herein are hereby expressly incorporated herein in their entireties by reference.

Claims

1. A method of treating a tumor in a subject in need thereof, comprising administering to said subject a therapeutically effective amount of a combination comprising a growth factor receptor inhibitor with an IAP inhibitor.

2. The method according to claim 1 wherein said IAP inhibitor inhibits the binding of the second mitochondria-derived activator of caspase (Smac) protein to inhibitor of apoptosis (IAPs) (IAP inhibitor).

3. The method according to claim 1 wherein growth factor receptor inhibitor is selected from the group of: i) a platelet-derived growth factor (PDGF) receptor tyrosine kinase inhibitor; ii) a human epidermal growth factor type 1 /epidermal growth factor receptor (HERl /EGFR) inhibitor; iii) epidermal growth factor (EGF) receptor protein tyrosine kinase inhibitor; iv) inhibitors of the insulin-like Growth Factor I Receptor; and v) combinations thereof.

4. The method according to claim 3 wherein said PDGF receptor tyrosine kinase inhibitor is selected from a compound of formula III, IV, and combinations thereof:

5. The method according to claim 1 wherein said IAP inhibitor is a compound according to formula I:

R] is H; Ci-Qalkyl; C_!-C₄alkenyl; C₁-C₄alkynyl or C₃-C₁₀cycloalkyl which are unsubstituted or substituted;

R₂ is H; Ci-C₄alkyl; C_!-C₄alkenyl; C_!-C₄alkynyl or C₃-C₁₀cycloalkyl which are unsubstituted or substituted;

R₃ is H; -CF₃; -C₂F₅; d-C₄alkyl; d-C₄alkenyl; d-Calkynyl; -CH₂-Z, or

R₂ and R₃, together with the nitrogen, form a het ring; Z is H; -OH; F; Cl; -CH₃; -CF₃; -CH₂Cl; -CH₂F or -CH₂OH;

R₄ is Ci-Ci₆Straight or branched alkyl; Ci-C^alkenyl; Ci-Ci₆alkynyl; or -C₃- Ciocycloalkyl; -(CH₂)_1-6-Zi; -(CH₂)o_-6-arylphenyl; and -(CH₂)o_-6-het, wherein alkyl, cycloalkyl and phenyl are unsubstituted or substituted;

Z₁ is -N(R₈)-C(O)-C,-C₁₀alkyl; -N(Rg)-C(O)-(CH₂) _1-6-C₃-C₇cycloalkyl; -N(R₈)- C(O)-(CH₂)o_-6-phenyl; -N(Rg)-C(O)-(CH₂) ,.₆-het; -C(O)-N(R₉)(R₁₀); -C(O)-O-C₁-

Cioalkyl; -C(O)-O-(CH₂)₁.₆-C₃-C₇cycloalkyl; -C(O)-O-(CH₂)o_-6-phenyl; -C(O)-O-(CH₂) ,. ₆-het; -O-C(O)-Ci-C₁₀alkyl; -0-C(O)-(CH₂) _1-6-C₃-C₇cycloalkyl; -O-C(O)-(CH₂)_0-6- phenyl; -0-C(O)-(CH₂) _1-6-het, wherein alkyl, cycloalkyl and phenyl are unsubstituted or substituted; het is a 5- to 7-membered heterocyclic ring containing 1-4 heteroatoms selected from N, O and S, or an 8- to 12-membered fused ring system including at least one 5- to 7-membered heterocyclic ring containing 1 , 2 or 3 heteroatoms selected from N, O and S, which heterocyclic ring or fused ring system is unsubstituted or substituted on a carbon or nitrogen atom;

R₈ is H; -CH₃; -CF₃ ; -CH₂OH or -CH₂Cl;

R₉ and R_1O are each independently H; d-C₄alkyl; C₃-C₇cycloalkyl; -(CH₂)_1-6-C₃- C₇cycloalkyl; -(CH₂)o_-6-phenyl, wherein alkyl, cycloalkyl and phenyl are unsubstituted or substituted, or

R₉ and R₁₀, together with the nitrogen, form het;

R₅ is H; Ci-Cioalkyl; aryl; phenyl; C₃-C₇cycloalkyl; -(CH₂)_1-6-C₃-C₇cycloalkyl; - Ci-Cioalkyl-aryl; -(CH₂)o_-6-C₃-C₇cycloalkyl-(CH₂)_0-6-phenyl; -(CH₂)_0-4CH-((CH₂)_1-4- phenyl)₂; -(CH₂)_0-6-CH(phenyl)₂; -indanyl; -C(O)-C₁-C₁₀alkyl; -C(O)-(CH₂)_1-6-C₃- C₇cycloalkyl; -C(O)-(CH₂)₀.₆-phenyl; -(CH₂)_0-6-C(O)-phenyl; -(CH₂)₀.₆-het; -C(O)- (CH₂)_1-6-het, or

R₅ is a residue of an amino acid, wherein the alkyl, cycloalkyl, phenyl and aryl substituents are unsubstituted or substituted; U is a as shown in structure II:

wherein n = 0-5;

X is -CH or N; Ra and Rb are independently an O, S or N atom or Co-Csalkyl, wherein one or more of the carbon atoms in the alkyl chain may be replaced by a heteroatom selected from O, S or N, and where the alkyl may be unsubstituted or substituted;

Rd is selected from:

(a) -Re-Q- (Rf)_p(Rg)_q; or (b) ATi-D-Ar₂; or

(c) Ar₁-D-;

Re is Ci.C₈alkyl or alkylidene, and Re which may be unsubstituted or substituted;

Q is N, O, S, S(O) or S(O)₂;

Ari and Ar₂ are substituted or unsubstituted aryl or het; Rf and Rg are each independently none, or H; -Ci-C₁₀alkyl; Q-Cioalkylaryl; -

OH; -O-Ci-Ci₀alkyl; -(CH₂)_0-6-C₃-C₇cycloalkyl; -O-(CH₂)_0-6-aryl; phenyl; aryl; phenyl- phenyl; -(CH₂)_1-6-het; -O-(CH₂)_1-6-het; -OR₁₁; -C(O)-R₁₁; -C(O)-N(R₁₁)(Ri₂); -N(R₁₁)(R₁₂); -S-R_{1 1}; -S(O)-R₁₁; -S(O)₂-R₁₁; -S(O)₂-NR₁₁R₁₂; -NR₁₁-S(O)₂- R₁₂; S-C₁- Cioalkyl; aryl-Ci-C₄alkyl; het-Cj-C₄alkyl, wherein alkyl, cycloalkyl, het and aryl are unsubstituted or substituted; -SO_2-C_1-C₂alkyl; -SO_2-C i.C₂alkylphenyl; -O-C₁-C₄alkyl, or

Rg and Rf form a ring selected from het or aryl; and

D is -CO-; -C(O)-or Ci-C₇alkylene or arylene; -CF₂-; -O-; -or S(O)_m, where rn is 0-2; 1 ,3dioaxolane; or Ci.C₇alkyl-OH, where alkyl, alkylene or arylene may be unsubstituted or substituted with one or more halogens, OH, -O-Ci-C₆alkyl, -S-C₁- Qalkyl or -CF₃, or

D is -N(Rh), wherein Rh is H; Q-C-zalkyl (unsubstituted or substituted); aryl; - O(Ci.C₇cycloalkyl) (unsubstituted or substituted); C(O)-Ci-Ci₀alkyl; C(O)-C₀-C₁₀alkyl- aryl; C-O-C₁ -C ₁₀alkyl; C-O-C₀-C₁₀alkyl-aryl; SO₂-Ci₀-Ci₀-alkyl; or SO₂-(Co-C₁O- alkylaryl); R₆, R₇, R'₆ and R'₇ are each independently H; -Ci-Ci_Oalkyl; -Ci-Cioalkoxy; aryl-

Ci-C₁₀alkoxy; -OH; -O-Ci-Ci₀alkyl; -(CH₂)_0-6-C₃-C₇cycloalkyl; -O-(CH₂)_0-6-aryl; phenyl; -(CH₂), _-6-het; -O-(CH₂)_1-6-het; -OR₁₁; -C(O)-R₁₁; -C(O)-N(R₁₁)(R₁₂); - N(R₁₁)(R₁₂); -S-R₁₁; -S(O)-R₁₁; -S(O)₂-R₁₁; -S(O)₂-NR₁₁R₁₂; -NR₁₁-S(O)₂- R₁₂, wherein alkyl, cycloalkyl and aryl are unsubstituted or substituted; and R₆, R₇, R'₆ and R'₇ can be united to form a ring system; and

Rn and R₁₂ are independently H; Ci-C₁₀alkyl; -(CH₂)_0-6-C₃-C₇cycloalkyl; - (CH₂)_0-6-(CH)_0-1(aryl)_1-2; -C(O)-C₁ -C ₁₀alkyl; -C(O)-(CH₂) _{1 -6}-C₃-C₇cycloalkyl; -C(O)-O- (CH₂)_0-6-aryl; -C(O)-(CH₂)_0-6-O-fluorenyl; -C(O)-NH-(CH₂)_0-6-aryl; -C(O)-(CH₂)_0-6-aryl; -C(O)-(CH₂) _1-6-het; -C(S)-C₁-Ci_OaIlCyI; -C(S)-(CH₂) i_-6-C₃-C₇cycloalkyl; -C(S)-O-(CH₂)_0- ₆-aryl; -C(S)-(CH₂)_0-6-O-fluorenyl; -C(S)-NH-(CH₂)_0-6-aryl; -C(S)-(CH₂)₀.₆-aryl; -C(S)- (CH₂) i_-6-het, wherein alkyl, cycloalkyl and aryl are unsubstituted or substituted, or

Rn and R₁₂ are a substituent that facilitates transport of the molecule across a cell membrane, or

R₁₁ and Rj₂, together with the nitrogen atom, form het, wherein the alkyl substituents of Rn and Rj₂ may be unsubstituted or substituted by one or more substituents selected from Ci-C₁₀alkyl, halogen, OH, -O-C_!-C₆alkyl, -S-Ci- C₆alkyl or -CF₃; substituted cycloalkyl substituents of Rj i and Ri₂ are substituted by one or more substituents selected from a Ci-Cioalkene; Ci-Cβalkyl; halogen; OH; -O-Ci- C₆alkyl; -S-Ci-C₆alkyl or -CF₃; and substituted phenyl or aryl of Rn and Rj₂ are substituted by one or more substituents selected from halogen; hydroxy; Ci-C₄alkyl; Ci-C₄alkoxy; nitro; -CN; -O- C(O)-Ci-C₄alkyl and -C(O)-O-Ci-C₄aryl.

6. The method according to Claim 5, wherein the compound of formula I is N-[I- cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2- methylamino-propionamide.

7. The method according to Claim 5, wherein the compound of formula I is (S)-N- ((S)- 1 -cyclohexyl-2- { (S)-2- [4-(4-fluoro-benzoyl)-thiazol-2-yl] -pyrrolidin- 1 -yl } -2-oxo- ethyl)-2-methylamino-propionamide.

8. A pharmaceutical composition comprising a combination comprising a growth factor receptor inhibitor with an IAP inhibitor, optionally together with a pharmaceutical carrier.

9. The pharmaceutical composition according to Claim 8, wherein said IAP inhibitor is a compound according to formula I:

and pharmaceutically acceptable salts, enantiomers, stereoisomers, rotamers, tautomers, diastereomers, or racemates thereof; wherein R₁ is H; Ci-C₄alkyl; C₁-C₄alkenyl; Ci-C₄alkynyl or C₃-C₁₀cycloalkyl which are unsubstituted or substituted;

R₂ is H; Ci-C₄alkyl; d-C₄alkenyl; Ci-C₄alkynyl or C₃-C₁₀cycloalkyl which are unsubstituted or substituted;

R₃ is H; -CF₃; -C₂F₅; d-C₄alkyl; Ci-C₄alkenyl; Ci-C₄alkynyl; -CH₂-Z, or R₂ and R₃, together with the nitrogen, form a het ring;

Z is H; -OH; F; Cl; -CH₃; -CF₃; -CH₂Cl; -CH₂F or -CH₂OH;

R₄ is Ci-Ci₆straight or branched alkyl; Ci-Cj₆alkenyl; d-Ci₆alkynyl; or -C₃- Ci₀cycloalkyl; -(CH₂)i_-6-Zi; -(CH₂)_0-6-arylphenyl; and -(CH₂)_0-6-het, wherein alkyl, cycloalkyl and phenyl are unsubstituted or substituted; Z₁ is -N(R₈)-C(O)-C₁-C₁₀alkyl; -N(R₈)-C(O)-(CH₂)_1-6-C₃-C₇cycloalkyl; -N(R₈)-

C(O)-(CH₂)_0-6-phenyl; -N(R₈)-C(O)-(CH₂)_1-6-het; -C(O)-N(R₉)(R₁₀); -C(O)-O-C₁- C₁₀alkyl; -C(O)-O-(CH₂)_1-6-C₃-C₇cycloalkyl; -C(O)-O-(CH₂)_0-6-phenyl; -C(O)-O-(CH₂)_L ₆-het; -0-C(O)-C₁-C_1OaIlCyI; -O-C(O)-(CH₂),_-6-C₃-C₇cycloalkyl; -O-C(O)-(CH₂)_0-6- phenyl; -0-C(O)-(CH₂) _1-6-het, wherein alkyl, cycloalkyl and phenyl are unsubstituted or substituted; het is a 5- to 7-membered heterocyclic ring containing 1-4 heteroatoms selected from N, O and S, or an 8- to 12-membered fused ring system including at least one 5- to 7-membered heterocyclic ring containing 1 , 2 or 3 heteroatoms selected from N, O and S, which heterocyclic ring or fused ring system is unsubstituted or substituted on a carbon or nitrogen atom;

R₈ is H; -CH₃; -CF₃ ; -CH₂OH or -CH₂Cl;

R₉ and R_]0 are each independently H; Ci-C₄alkyl; C₃-C₇cycloalkyl; -(CH₂)_I-6-C₃- C₇cycloalkyl; -(CH₂)o-₆-phenyl, wherein alkyl, cycloalkyl and phenyl are unsubstituted or substituted, or Rg and R₁₀, together with the nitrogen, form het;

R₅ is H; Ci-Cioalkyl; aryl; phenyl; C₃-C₇cycloalkyl; -(CH₂)i_-6-C₃-C₇cycloalkyl; C₁-C,oalkyl-aryl; -(CH₂)_0-6-C₃-C₇cycloalkyl-(CH₂)_0-6-phenyl; -(CH₂)_0-4CH-((CH₂)_1-4- phenyl)₂; -(CH₂)₀-₆-CH(phenyl)₂; -indanyl; -C(O)-C₁ -C ₁₀alkyl; -C(O)-(CH₂)^-C₃- C₇cycloalkyl; -C(0)-(CH₂)o_-6-phenyl; -(CH₂)_0-6-C(O)-phenyl; -(CH₂)_0-6-het; -C(O)- (CH₂)_1-6-het, or

R₅ is a residue of an amino acid, wherein the alkyl, cycloalkyl, phenyl and aryl substituents are unsubstituted or substituted;

U is a as shown in structure II:

wherein n = 0-5; X is -CH or N;

Ra and Rb are independently an O, S or N atom or Co-Csalkyl, wherein one or more of the carbon atoms in the alkyl chain may be replaced by a heteroatom selected from O, S or N, and where the alkyl may be unsubstituted or substituted; Rd is selected from:

(a) -Re-Q- (Rf)_p(Rg)_q; or

(b) Ar₁-D-Ar₂; or (c) Ar₁-D-;

Re is Cj.Qalkyl or alkylidene, and Re which may be unsubstituted or substituted;

Q is N, O, S, S(O) or S(O)₂;

Ari and Ar₂ are substituted or unsubstituted aryl or het;

Rf and Rg are each independently none, or H; -Ci-Ci_Oalkyl; Ci-Ci_Oalkylaryl; - OH; -O-d-Cioalkyl; -(CH₂)o.₆-C₃-C₇cycloalkyl; -O-(CH₂)_0-6-aryl; phenyl; aryl; phenyl- phenyl; -(CH₂) _1-6-het; -0-(CH₂) _1-6-het; -OR_{1 1}; -C(O)-R₁₁; -C(O)-N(R₁₁)(R₁₂); -N(R₁₁)(R₁₂); -S-R_{1 1}; -S(O)-R₁₁; -S(O)₂-R₁₁; -S(O)₂-NR₁₁R₁₂; -NR₁₁-S(O)₂- R₁₂; S-C₁- C₁₀alkyl; aryl-C₁-C₄alkyl; het-Ci-C₄alkyl, wherein alkyl, cycloalkyl, het and aryl are unsubstituted or substituted; -SO₂.C₁.C₂alkyl; -SO_2-C_1-C₂alkylphenyl; -O-Ci-C₄alkyl, or Rg and Rf form a ring selected from het or aryl; and

D is -CO-; -C(O)-Or C_1-C₇alkylene or arylene; -CF₂-; -0-; -or S(0)_m, where rn is 0-2; l,3dioaxolane; or Ci.C₇alkyl-OH, where alkyl, alkylene or arylene may be unsubstituted or substituted with one or more halogens, OH, -O-C]-C₆alkyl, -S-C₁- C₆alkyl or -CF₃, or D is -N(Rh), wherein Rh is H; C_1-C₇alkyl (unsubstituted or substituted); aryl; -

O(C_1-C₇cycloalkyl) (unsubstituted or substituted); C(O)-d-C₁₀alkyl; C(O)-C₀-C ₁₀alkyl- aryl; C-O-d-Ci₀alkyl; C-O-Co-Cioalkyl-aryl; SO₂-C₁₀-C₁₀-alkyl; or SO₂-(C₀-Ci₀- alkylaryl);

R₆, R₇, R'₆ and R'₇ are each independently H; -Ci-C]_Oalkyl; -Ci-Ci₀alkoxy; aryl- d-C₁₀alkoxy; -OH; -O-d-Cioalkyl; -(CH₂)_0-6-C₃-C₇cycloalkyl; -O-(CH₂)_0-6-aryl; phenyl; -(CH₂) _1-6-het; -0-(CH₂) _1-6-het; -OR₁₁; -C(O)-R₁₁; -C(O)-N(R₁₁)(R₁₂); - N(R₁₁)(R₁₂); -S-R₁₁; -S(O)-R₁₁; -S(O)₂-R₁₁; -S(O)₂-NR₁₁R₁₂; -NR₁₁-S(O)₂- R₁₂, wherein alkyl, cycloalkyl and aryl are unsubstituted or substituted; and R₆, R₇, R'₆ and R'₇ can be united to form a ring system; and R₁₁ and R₁₂ are independently H; Ci-C₁₀alkyl; -(CH₂)_0-6-C₃-C₇cycloalkyl; -

(CH₂)_0-6-(CH)_0-1(aryl)_1-2; -C(O)-C,-Ci₀alkyl; -C(O)-(CH₂)_1-6-C₃-C₇cycloalkyl; -C(O)-O- (CH₂)_0-6-aryl; -C(O)-(CH₂)_0-6-O-fluorenyl; -C(O)-NH-(CH₂)_0-6-aryl; -C(O)-(CH₂)_0-6-aryl; -C(O)-(CH₂)_1-6-het; -C(S)-Ci-C₁₀alkyl; -C(S)-(CH₂)_1-6-C₃-C₇cycloalkyl; -C(S)-O-(CH₂)_0- ₆-aryl; -C(S)-(CH₂)_0-6-O-fluorenyl; -C(S)-NH-(CH₂)_0-6-aryl; -C(S)-(CH₂)_0-6-aryl; -C(S)- (CH₂)i_-6-het, wherein alkyl, cycloalkyl and aryl are unsubstituted or substituted, or

Ri i and Ri₂ are a substituent that facilitates transport of the molecule across a cell membrane, or

Rn and Ri₂, together with the nitrogen atom, form het, wherein the alkyl substituents of Rj i and Ri₂ may be unsubstituted or substituted by one or more substituents selected from Ci-Cioalkyl, halogen, OH, -O-Ci-C₆alkyl, -S-Ci- C₆alkyl or -CF₃; substituted cycloalkyl substituents of Rn and R₁₂ are substituted by one or more substituents selected from a Ci-C₁₀ alkene; Ci-C₆alkyl; halogen; OH; -0-C₁-

Qalkyl; -S-Ci-C₆alkyl or -CF₃; and substituted phenyl or aryl of Rn and Ri ₂ are substituted by one or more substituents selected from halogen; hydroxy; Cj-C₄alkyl; Ci-C₄alkoxy; nitro; -CN; -O-

C(O)-Ci-C₄alkyl and -C(O)-O-Ci-C₄aryl.

10. A pharmaceutical composition according to Claim 9, wherein the compound of formula I is N-[l-cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l- yl)-ethyl]-2-methylamino-propionamide.

11. A pharmaceutical composition according to Claim 9, wherein the compound of formula I is (5)-N-((5)-l-cyclohexyl-2-{(5)-2-[4-(4-fluoro-benzoyl)-thiazol-2-yl]- pyrrolidin- 1 -yl } -2-oxo-ethyl)-2-methylamino-propionamide.

12. A method of treating gliomas in a subject in need thereof, comprising administering to said subject a therapeutically effective amount of the pharmaceutical composition according to Claim 9.

13. A commercial package comprising a combination of a compound of formula I and III useful in glioma treatment, together with instructions for simultaneous, separate or sequential use thereof in the treatment of gliomas.

14. A commercial package comprising a combination of a compound of formula I and IV useful in glioma treatment, together with instructions for simultaneous, separate or sequential use thereof in the treatment of gliomas.

15. The use of a combination of a compound of formula I and III for the preparation of a medicament for the treatment of gliomas.

16. The use of a combination of a compound of formula I and IV for the preparation of a medicament for the treatment of gliomas.

17. A combination comprising a therapeutically effective amount of a growth factor receptor inhibitor with an IAP inhibitor.

18. The combination according of Claim 15, wherein the compound of formula I is N-[l-cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2- methylamino-propionamide.

19. The combination according of Claim 15, wherein the compound of formula I is (5)-iV-((5)-l-cyclohexyl-2-{(5)-2-[4-(4-fluoro-benzoyl)-thiazol-2-yl]-pyrrolidin-l-yl}-2- oxo-ethyl)-2-methylamino-propionamide.

20. The combination according of Claim 16, wherein the compound of formula I is N-[l-cyclohexyl-2-oxo-2-(6-phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2- methylamino-propionamide.

21. The combination according of Claim 16, wherein the compound of formula I is (S)-N-((S)- 1 -cyclohexyl-2- { (S)-2- [4-(4-fluoro-benzoyl)-thiazol-2-yl] -pyrrolidin- 1 -yl } -2- oxo-ethyl)-2-methylamino-propionamide.

22. A pharmaceutical composition comprising (iS)-N-((5)-l-cyclohexyl-2-{(5)-2-[4- (4-fluoro-benzoyl)-thiazol-2-yl] -pyrrolidin- 1 -yl } -2-oxo-ethyl)-2-methylamino- propionamide and PKI 166.

23. A pharmaceutical composition comprising (5)-N-((5)-l-cyclohexyl-2-{(iS)-2-[4- (4-fluoro-benzoyl)-thiazol-2-yl]-pyrrolidin-l-yl}-2-oxo-ethyl)-2-methylamino- propionamide and AEW541.

24. A pharmaceutical composition comprising (S)-N-((S)- 1 -cyclohexyl-2- {(5)-2- [4- (4-fluoro-benzoyl)-thiazol-2-yl] -pyrrolidin- 1 -yl } -2-oxo-ethyl)-2-methylamino- propionamide and AMΝ 107.

25. A pharmaceutical composition comprising (S)-N-(OS)- l-cyclohexyl-2-{(5)-2-[4- (4-fluoro-benzoyl)-thiazol-2-yl]-pyrrolidin- 1 -yl} -2-oxo-ethyl)-2-methylamino- propionamide and imatinib.

26. A pharmaceutical composition comprising N-[I -eye lohexyl-2-oxo-2-(6- phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2-methylamino-propionamide and PKI 166.

27. A pharmaceutical composition comprising N-[ 1 -cyclohexyl-2-oxo-2-(6- phenethyl-octahydro-pyrrolo[2,3-c]pyridin-l-yl)-ethyl]-2-methylamino-propionamide and AEW541.

28. A pharmaceutical composition comprising N-[l-cyclohexyl-2-oxo-2-(6- phenethyl-octahydro-pyrrolo [2,3 -c]pyridin- 1 -yl)-ethyl] -2-methylamino-propionamide and AMΝ107.

29. A pharmaceutical composition comprising N-[I -cyclohexyl-2-oxo-2-(6- phenethyl-octahydro-pyrrolo [2,3 -c]pyridin- 1 -yl)-ethyl] -2-methylamino-propionamide and imatinib.