WO2011022782A1

WO2011022782A1 - Combinations comprising imatinib mesylate and diclofenac

Info

Publication number: WO2011022782A1
Application number: PCT/AU2010/001109
Authority: WO
Inventors: Timothy Peter Hughes; Deborah White; Richard James D'andrea
Original assignee: Medvet Science Pty Ltd
Priority date: 2009-08-27
Filing date: 2010-08-27
Publication date: 2011-03-03

Abstract

The present invention relates to a method of treating Philadelphia-positive leukemia (Ph+ leukemia), especially chronic myeloid leukemia (CML), especially in human patients having low OCT-1 Activity ("low OA patients"), a combination comprising (a) imatinib or a pharmaceutically acceptable salt thereof and (b) diclofenac or a pharmaceutically acceptable salt thereof, the use of such combination for the manufacture of a medicament for the treatment of Ph+ leukemia and to a pharmaceutical composition comprising a quantity which is jointly therapeutically effective against a proliferative disease of a such combination.

Description

Combinations Comprising lmatinib Mesylate and Diclofenac

The present invention relates to a method of treating Philadelphia-positive leukemia (Ph+ leukemia), especially chronic myeloid leukemia (CML), especially in human patients ing low OCT-1 Activity ("low OA patients"), using a combination comprising (a) imatinib or a pharmaceutically acceptable salt thereof and (b) diclofenac or a pharmaceutically acceptable salt thereof.

In May 2001 the mesylate salt of N-{5-[4-(4-methyl-piperazino-methyl)-benzoylamido]-2- methylphenyl}-4-(3-pyridyl)-2-pyrimidine-amine (imatinib mesylate, STI571B, Glivec®) was approved by the FDA for the treatment of CML in patients who had failed to benefit from IFN-alpha therapy. The success of treatment with imatinib mesylate in the majority of chronic phase CML patients is well established.

Improving treatment outcomes for those patients who perform less well however requires a detailed understanding of the critical determinants of treatment response. It was previously demonstrated that intrinsic sensitivity to imatinib-induced kinase inhibition is a good predictor of response (White D, Saunders V, Lyons AB, et al. Blood.

2005;106:2520-2526; Schultheis B, Szydlo R, Mahon FX, Apperley JF, MeIo JV. Blood. 2005; 105:4893-4894) and that this is closely related to the intracellular uptake and retention (IUR) of imatinib (White DL, Saunders VA, Dang P, et al. Blood. 2006; 108:697- 704). Further it has been demonstrated that the active transport of imatinib is dependent on the organic cation transporter OCT-1 (Thomas J, Wang L, Clark RE, Pirmohamed M. Blood. 2004;104:3739-3745; White DL, Saunders VA, Dang P, et al, OCT-1 mediated influx is a key determinant of the intracellular uptake of imatinib but not nilotinib. Blood. 2006; 108: 697-704).

The OCT-1 protein is a member of the largest superfamily of transporters, the solute carrier family (Koepsell H, Endou H. Pflugers Arch. 2004;447:666-676) which transport in an electrogenic fashion a variety of organic cations, including drugs, toxins and other xenobiotics. The transporter is predicted to have 12 transmembrane domains, and binding pockets with partially overlapping interaction domains for different substrates and inhibitors (Koepsell H, Schmitt BM, Gorboulev V. Rev Physiol Biochem Pharmacol. 2003; 150:36-90). Post transcriptional regulation of OCT-1 by phosphorylation status (Ciarimboli G, Schlatter E. Pflugers Arch. 2005;449:423-441) and such compounds as PKA, Src-like p56 and CaM have also been demonstrated.

It was demonstrated by comparing OCT-1 Activity with molecular response in patients enrolled to the TIDEL trial (chronic phase newly diagnosed CML patients who received 600 mg lmatinib mesylate up-front) that patients with high OCT-1 Activity achieve significantly greater molecular responses over 24 months of lmatinib treatment than patients with low OCT-1 Activity (WO2009/000023). Further it was found that the molecular response of those patients with low OCT-1 Activity is highly dose dependent, with patients receiving 600 mg of lmatinib mesylate achieving significantly better molecular response by 24 months. While increasing imatinib dose may partially overcome the negative effects of low OCT-1 Activity, this is often poorly tolerated.

OCT-1 Activity as referred to herein and in WO2009/000023 is calculated as the difference in IUR in the absence (total IUR) and presence of prazosin, to provide a measure of the actual activity of the OCT-1 protein in the transport of imatinib. For example: [Total IUR 32ng/200,000 cells)] - [prazosin IUR 23ng/200,000 cells] gives an OCT-1 Activity of 9ng/200,000 cells. Experimental procedures for determining the OCT-1 Activity are described in more detail in WO2009/000023. However, the present invention also embraces corresponding methods employing alternative assays or processes for determining the OCT-1 Activity. Methods for the determination of the OCT-Activity are, for instance, described in Blood, 2007 Dec 1 ; 110(12):4064-72.

Surprisingly, it was now found that the combined use of (a) imatinib or a pharmaceutically acceptable salt thereof and (b) the non-steroidal anti-inflammatory drug diclofenac or a pharmaceutically acceptable salt thereof can significantly improve the response of low OA patients, abrogating the need for imatinib dose increase or switching to alternative second line inhibitor therapy.

In the Examples below it is demonstrate that the non-steroidal anti-inflammatory drug diclofenac results in significant increases in OCT-1 Activity, particularly in cells obtained from low OA patients. In cells from previously untreated CP-CML patients- a significant increase in OA in the presence of diclofenac is demonstrated at clinically relevant concentrations. Importantly from a clinical perspective, this increase is shown to be highly significant in the quartile 1 patients who have a particularly poor outcome on standard lmatinib mesylate therapy.

The studies presented below suggest that the well-tolerated drug diclofenac may be able to enhance lmatinib mesylate uptake resulting in a significant increase in kinase inhibition.

Short Description of the Figures

Figure 1A: Demonstrating the % increase in OA observed in the presence of diclofenac and other OA enhancer. The % increase is determined as the % change in OA from that observed in the absence of OA-E (p=0.038). Error bars represent SEM.

Figure 1 B: The effect of diclofenac on the IC50 ^ιmatιnιb in the presence and absence of this enhancer. This demonstrates that the increased OA mediated by the enhancer translates to an increase in kinase inhibition and concomitant decrease in the IC50 ^ιmatιnιb

Figure 1C: Cumulative IC50'^matιnιb results for the cell line K562 in the presence of no OA enhancer (IC50 ^ιmatιnιb- 6.7uM), fasudil (IC50 ^ιmat'^nιb- 4.8uM), LM1685 (IC50 ^ιmatιnιb- 4.5uM) and diclofenac (IC50 ^ιmatιnib- 3.6uM). This demonstrates that the increased OA mediated by the enhancer translates to an increase in kinase inhibition and concomitant decrease in IC50^imatιnιb.

Fig. 2 - The % of patients achieving a MMR by 24 months in the TDEL trial patients were grouped on their OA quartile (Q1 <4 ng/200,000 cells) Q2 (>4 <7.2 ng/200,000 cells. Q3 >7.2<10ng/200,000 cells and Q4 >10ng/200,000 cells.

Hence, the present invention pertains to a combination which comprises (a) lmatinib or a pharmaceutically acceptable salt thereof and (b) diclofenac or a pharmaceutically acceptable salt thereof, and optionally at least one pharmaceutically acceptable carrier; for simultaneous, separate or sequential use. lmatinib is specifically disclosed in the patent applications US 5,521 ,184. lmatinib can also be prepared in accordance with the processes disclosed in WO03/066613. For the purpose of the present invention, lmatinib is preferably applied in the form of its mono-mesylate salt, lmatinib mono-mesylate can be prepared in accordance with the processes disclosed in US 6,894,051. Comprised by the present invention are likewise the corresponding polymorphs, e.g. crystal modifications, which are disclosed in US 6,894,051.

In one embodiment of the invention the mono-mesylate salt of lmatinib is administered orally in dosage forms as described in US 5,521 ,184, US 6,894,051 or US 2005-0267125. The mono-mesylate salt of lmatinib is marketed under the brand Glivec® (Gleevec®). In the present invention, the preferred oral dosage of lmatinib is 200 - 600 mg/day, more preferably 400 mg/day, administered as a single dose or divided into multiple doses, such as twice daily dosing.

Diclofenac can be used in the form of its sodium salt as described in US 3,558,690, but also as diethylammonium salt as described in US 4,407,824. Suitable formulations for diclofenac are disclosed, for instance, in US 4,91 ,7886 and US 2007-0128277. Diclofenac sodium is also known as Voltaren™.

The structure of the active agents identified by generic or trade names may be taken from the actual edition of the standard compendium "The.Merck Index" or from databases, e.g. Patents International (e.g. IMS World Publications).

In the herein disclosed methods, combinations, compositions or uses, the combination partners (a) and (b) are preferably administered in synergistically effective amounts.

Chronic myeloid leukemia (CML) belongs to the group of Ph+ leukemia. The results obtained with the CML patient population described herein can be directly transferred to the whole group of Ph+ leukemias, e.g. Ph+ CML and Ph+ ALL. The reason for that is that the characterizing feature of Ph+ leukemias is the existence of the Philadelphia chromosome causing the Bcr-Abl fusion protein. The latter protein is the target of lmatinib. The abbreviation "Ph+ ALL" as used herein denotes Philadelphia chromosome positive acute lymphoblastic leukemia.

The abbreviation "CP" as used herein denotes "chronic phase".

In a particular aspect, the present invention relates to a method of treating Ph+ leukemia, preferably CML in a human patient population.

The term "method of treatment" as used herein relates also to a method of prevention of the diseases mentioned herein, i.e. the prophylactic administration of a pharmaceutical composition comprising lmatinib mesylate to healthy patients to prevent the development of the diseases mentioned herein.

Collecting blood samples from CML patients required according to the methods described herein can be accomplished by standard procedures being state of the art.

The combination described herein can be applied as a combined preparation or as a pharmaceutical composition.

The term "a combined preparation", as used herein defines especially a "kit of parts" in the sense that the combination partners (a) and (b) as defined above can be dosed independently or by use of different fixed combinations with distinguished amounts of the combination partners (a) and (b), 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 combination partners (a) and (b). The ratio of the total amounts of the combination partner (a) to the combination partner (b) 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 the particular disease, 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 combination partners (a) and (b), 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 combination partners (a) and (b), and very preferably a strong synergism of the combination partners (a) and (b).

The pharmaceutical compositions for separate administration of the combination partners (a) and (b) and for the administration in a fixed combination, i.e. single galenical compositions comprising at least two combination partners (a) and (b), according to the invention can be prepared in a manner known per se and are those suitable for enteral, such as oral or rectal, and parenteral administration to mammals (warm-blooded animals), including man, comprising a therapeutically effective amount of at least one pharmacologically active combination partner alone or in combination with one or more pharmaceutically acceptable carriers, especially suitable for enteral or parenteral application.

Moreover, the present invention provides a commercial package comprising a

combination of lmatinib or a pharmaceutically salt thereof and diclofenac or a

pharmaceutically acceptable salt thereof, together with instructions for simultaneous, separate or sequential use thereof for the therapeutic purposes as described herein.

Furthermore, the present invention relates to

(i) the use of a combination which comprises (a) N-{5-[4-(4-methyl-piperazino-methyl)- benzoylamido]-2-methylphenyl}-4-(3-pyridyl)-2-pyrimidine-amine (lmatinib) or a pharmaceutically acceptable salt thereof and (b) diclofenac or a pharmaceutically acceptable salt thereof for the manufacture of a medicament for the treatment of Ph+ leukemia, and

(ii) a method of treating Ph+ leukemia in a warm-blooded animal, especially a human, comprising the steps of

(a) determining the OCT-1 Activity in pre-therapy blood of the warm-blooded animal, especially a human, suffering from Ph+ leukemia, and

(b) administering a combination which comprises (a) N-{5-[4-(4-methyl-piperazino- methyl)-benzoylamido]-2-methylphenyl}-4-(3-pyridyl)-2-pyrimidine-amine (lmatinib) or a pharmaceutically acceptable salt thereof and (b) diclofenac or a pharmaceutically acceptable salt thereof to the warm-blooded animal, especially a human, suffering from Ph+ leukemia showing an OCT-1 Activity below 6.0 to 10.0 ng/200,000 cells, especially an OCT-1 Activity below 8.0 to 8.5 ng/200,000 cells.

Examples

The following Examples illustrate the invention described above, but is not, however, intended to limit the scope of the invention in any way. Other test models known as such to the person skilled in the pertinent art can also determine the beneficial effects of the claimed invention.

Cell lines

Human K562 and KU812 cell lines were obtained from the American Type Culture Collection (ATCC, Manassas, VA). Kidney and liver cell lines were kindly provided by Dr Andrew Zannettino SA Pathology Adelaide, Australia.

Patient Samples

Blood was obtained from newly diagnosed, chronic phase CML patients, prior to the commencement of imatinib therapy. Normal blood was obtained from healthy volunteers. All blood samples were collected with informed consent in accordance with the

Declaration of Helsinki.

Radiolabeled Drug Uptake (IUR Assay) IC50^imatinib OA Assay and OCT-1 mRNA analysis

TThhee IIUURR₁₁ lC50'^matιmb, and OA assays were performed as previously described (e.g. White

DL, Saunders VA, Dang P₁ et al. Blood. 2007; 110:4064-4072).

Example 1 - OcM Activity Assessment of the Effect of Diclofenac

10 μM Diclofenac were added to the 2 hour OCT-1 Activity assay (White DL₁ Saunders VA, Dang P, et al. Blood. 2007; 110:4064-4072) simultaneously with radio-labelled imatinib. OCT-1 Activity (OA) levels in the presence of diclofenac were compared to the OA in the absence of diclofenac. A greater than 134% increase in OA (2.8ng/200,000 cells in absence of diclofenac) was observed in K562 cells treated with 10μM diclofenac (N=4; p=0.038). A 36% increase was observed in OA (5.3ng/200,000 cells in absence of diclofenac) when diclofenac was tested in KU812 cells (N=3:p=0.112). Example 2 - IC50^imatinib Assay: Assessment of the Effect of Diclofenac

The IC50 assay was performed as previously described (see e.g. WO2009/000023), based on the in vitro reduction in the level of p-Crkl as a result of exposure to increasing concentrations of imatinib. The effect of diclofenac was determined by comparison of the IC50 in the presence and absence of diclofenac in cell lines and primary patient material. A significant decrease in the IC50^ιmatιnιbwas observed in K562 cells treated with diclofenac (6.8 to 3.6 μM: n=3. Figure 1).

Example 3 - Molecular Response- TIDEL Trial Data

Comparative analysis on the impact of diclofenac was made in relation to the TIDEL Study. TIDEL was a Phase Il study in adult patients with newly diagnosed CML. All patients commenced imatinib at 600 mg/day where tolerated. In a previous study of TIDEL patients it was demonstrated that significantly more patients with a high OA achieve MMR than those with a low OA (low OA - 45% achieve MMR by 24 months versus high OA - 85% p=0.004) (White DL, Saunders VA, Dang P, et al. Blood.

2007; 110:4064-4072). Dissecting the OA groups further into quartiles we demonstrate that OA is a continuous variable, and that patients with OA in the lowest quartile have a significantly poorer response than those in higher quartiles. Irrespective of the IM dose received, only 29% of patients in Q1 achieve MMR by 24 months, compared to 60% of Q2 patients (p=0.039), 85% of Q3 patients and 86% of Q4 (p=0.025) (Figure 2).

To test the ability of diclofenac to increase OA the drugs was assessed in the mononuclear cells (MNC) from 56 CP-CML patient. The OA of the majority of samples had been previously determined, and the sample population was weighted towards patients with low OA, as this is the target population for pharmacological intervention. The OA was determined in all patients in the presence and absence of diclofenac and is summarised in Table 1. A significant increase in cells from the majority of patients is observed.

Notably, 100% of cases failing to demonstrate an increase on OA had activities in excess of 4 ng/200,000 cells. Thus enhancing OA seem be most effective in patients with low basal OA, and not as effective in patients with higher OA, a target population where OA enhancement may not be as clinically important.

Having defined a group of patients (Quartile 1) whose MNCs were associated with negligible or low OA and sub-optimal response to imatinib mesylate, we next assessed whether diclofenac could potentiate a change in patient OA profile, consistent with a significantly improved response. The effect of diclofenac was tested in cells from 28 of this group. A statistically significant rise in OA was demonstrated. Diclofenac resulted in a rise in 93% of the samples tested (p<0.001) (Table 2). Significantly, in a high proportion of patient cells this rise resulted in a shift from Q1 to Q2 or above (Table 2).

Addition of diclofenac to cells from patients in Q2 also resulted in an increase in OA and a shift of a number of patient cell profiles to Q3 (Table 2) though the rise seen here failed to reach statistical significance. Interestingly, in cells from several patients a statistically significant decrease in OA was observed with diclofenac (Table 3). This finding suggests that diclofenac may not be of clinical value in patients with OA above 4ng/200,000 cells.

Table 1

Table 2. Effect of Diclofenac on Q1 and Q2 patients

Demonstrating the effect of diclofenac in moving patients from Q1 to Q2 or above

Increase in P value Q1to Q2 Q1 to Q3 Q1 to Q4 OA

# patients

(%)

Quartile 1 patients

Diclofenac 26 (93%) <0.001 15 (55%) 1 (3%) 1 (3%) (n=28)

Quartile 2 patients

Q2 to Q3 Q2 to Q4

Diclofenac 10 (63%) 0.562 2 (13%) 1 (6%)

(n=16) Table 3 - Proportion of Q2 patients who decrease with diclofenac

Proportion of Q2 patients who decrease with diclofenac. In 31% of patients in Q2 a statistically significant decrease in the OA was realized in the presence of diclofenac.

Claims

WHAT IS CLAIMED IS:

1. A combination which comprises (a) N-{5-[4-(4-methyl-piperazino-methyl)- benzoylamido]-2-methylphenyl}-4-(3-pyridyl)-2-pyrimidine-amine (Imatinib) or a pharmaceutically acceptable salt thereof and (b) diclofenac or a pharmaceutically acceptable salt thereof, and optionally at least one pharmaceutically acceptable carrier; for simultaneous, separate or sequential use.

2. Combination according to claim 1 wherein the compound (a) is present in the form of its mono-methanesulfonate salt.

3. Combination according to claim 1 or 2 which is a combined preparation or a

pharmaceutical composition.

4. A pharmaceutical composition comprising a quantity which is jointly therapeutically effective against a proliferative disease of a combination according to claim 1 or 2 and at least one pharmaceutically acceptable carrier.

5. Use of a combination according to any one of claims 1 or 2 for the manufacture of a medicament for the treatment of Ph+ leukemia.

6. Method of treating Ph+ leukemia in a warm-blooded animal comprising the steps of

(a) determining the OCT-1 Activity in pre-therapy blood of the warm-blooded animal suffering from Ph+ leukemia, and

(b) administering a combination which comprises (a) N-{5-[4-(4-methyl-piperazino- methyl)-benzoylamido]-2-methylphenyl}-4-(3-pyridyl)-2-pyrimidine-amine (Imatinib) or a pharmaceutically acceptable salt thereof and (b) diclofenac or a pharmaceutically acceptable salt thereof to the warm-blooded animal suffering from Ph+ leukemia showing an OCT-1 Activity below 6.0 to 10.0 ng/200,000 cells.

7. Method according to claim 6 wherein the warm blooded animal is a human.

8. Method according to claim 7 wherein the human suffering from Ph+ leukemia is showing an OCT-1 Activity below 8.0 to 8.5 ng/200,000 cells.

9. Method according to claim 7 wherein 400 mg/day of lmatinib or a pharmaceutically acceptable salt thereof are administered.