Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
  • A61K31/519—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim ortho- or peri-condensed with heterocyclic rings
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
  • A61K31/4353—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom ortho- or peri-condensed with heterocyclic ring systems
  • A61K31/436—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom ortho- or peri-condensed with heterocyclic ring systems the heterocyclic ring system containing a six-membered ring having oxygen as a ring hetero atom, e.g. rapamycin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
  • A61K31/506—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim not condensed and containing further heterocyclic rings
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
  • A61P35/02—Antineoplastic agents specific for leukemia
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P7/00—Drugs for disorders of the blood or the extracellular fluid

Definitions

• MPNs Myeloproliferative neoplasms
• PV polycythemia vera
• ETS thrombocythemia
• CML chronic myelogenous leukemia
• CCL chronic neutrophilic leukemia
• JML juvenile myelomonocytic leukemia
• HES chronic eosinophilic leukemia
• disorders are grouped together because they share some or all of the following features: involvement of a multipotent hematopoietic progenitor cell, dominance of the transformed clone over the non-transformed hematopoietic progenitor cells, overproduction of one or more hematopoietic lineages in the absence of a definable stimulus, growth factor-independent colony formation in vitro, marrow hypercellularity, megakaryocyte hyperplasia and dysplasia, abnormalities predominantly involving chromosomes 1, 8, 9, 13, and 20, thrombotic and hemorrhagic diatheses, exuberant extramedullary hematopoiesis, and spontaneous transformation to acute leukemia or development of marrow fibrosis but at a low rate, as compared to the rate in CML.
• MPNs The incidence of MPNs varies widely, ranging from approximately 3 per 100,000 individuals older than 60 years annually for CML to 0.13 per 100,000 children from birth to 14 years annually for JML (Vardiman JW et al, Blood 100 (7): 2292-302, 2002).
• a combination therapy comprising an mTOR inhibitor and a JAK inhibitor.
• the combination therapy is useful for the treatment of a variety of cancers, including MPNs.
• the combination therapy is also useful for the treatment of any number of JAK-associated diseases.
• a combination therapy comprising an mTOR inhibitor and a JAK inhibitor.
• the JAK inhibitor has the general formula set forth in formula I:
• composition comprising an mTOR inhibitor and a JAK inhibitor.
• the compound of formula I is (3R)-3-cyclopentyl-3-[4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1- yljpropanenitrile (Compound A), or a pharmaceutically acceptable salt thereof.
• the JAK inhibitor is 5-Chloro-N 2 -[(lS)-1-(5- fluoropyrimidin-2-yl)emyl]-N 4 -(5-methyl-1H-pyrazol-3-yl)-pyrimidi
• the mTOR inhibitor is Everolimus (RADOOl) or 2-(4- amino-1-isopropyl-1H-pyrazolo[3,4-d]pyrimidin-3-yl)-1H-indol-5-ol (PP242).
• the combination therapy comprises Everolimus and Compound A, or a pharmaceutically acceptable salt thereof.
• the combination therapy comprises PP242 and Compound A, or a pharmaceutically acceptable salt thereof.
• the mTOR inhibitor and the JAK inhibitor are in a single formulation or unit dosage form.
• the single formulation or unit dosage form can further comprise a pharmaceutically acceptable carrier.
• the mTOR inhibitor and the JAK inhibitor are administered separately.
• the combination therapy provided herein is useful for the treatment of a JAK- associated disease in a subject.
• a method of treating cancer in a subject in need thereof comprising administering to the subject an effective amount of an mTOR inhibitor and a JAK inhibitor (e.g., a compound of formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)).
• the cancer is a myeloproliferative neoplasm.
• myeloproliferative neoplasms that can be treated using the combination therapy of the invention include, but are not limited to, chronic myeloid leukemia (CML),
• PV polycythemia vera
• E essential thrombocythemia
• PMF primary or idiopathic myelofibrosis
• chronic neutrophilic leukemia chronic eosinophilic leukemia
• chronic myelomonocytic leukemia juvenile myelomonocytic leukemia
• the combination therapy can be used for treatment of intermediate or high-risk myelofibrosis, including primary myelofibrosis, post- polycythemia vera myelofibrosis or post-essential thrombocythemia myelofibrosis.
• the subject is human.
• the treatment comprises co-administering an mTOR inhibitor and a JAK inhibitor (e.g., a compound of formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)).
• the mTOR inhibitor and the JAK inhibitor e.g., a compound of formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)
• the mTOR inhibitor and the JAK inhibitor are in a single formulation or unit dosage form.
• the mTOR inhibitor and the JAK inhibitor e.g., a compound of formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)
• the treatment comprises administering the mTOR inhibitor and the JAK inhibitor (e.g., a compound of formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)) at substantially the same time, or different times.
• the mTOR inhibitor is administered to the subject, followed by administration of the JAK inhibitor (e.g. , a compound of formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)).
• the JAK inhibitor e.g., a compound of formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)
• the mTOR inhibitor and/or the JAK inhibitor e.g., a compound of formula I (e.g.,
• Compound A, or a pharmaceutically acceptable salt thereof) is administered at amounts that would not be effective when one or both of the mTOR inhibitor and the JAK inhibitor (e.g. , a compound of formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)) is administered alone, but which amounts are effective in combination.
• the JAK inhibitor e.g. , a compound of formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)
• the combination therapy provided herein is also useful for inhibiting STAT5 phosphorylation.
• the STAT5 phosphorylation can be inhibited in a subject in need thereof.
• the inhibition of STAT5 phosphorylation in a subject treats a myeloproliferative neoplasm in the subject.
• the myeloproliferative neoplasm can be selected from the group consisting of chronic myeloid leukemia (C L), polycythemia vera (PV), essential thrombocythemia (ET), primary or idiopathic myelofibrosis (PMF), chronic neutrophilic leukemia, chronic eosinophilic leukemia, chronic myelomonocytic leukemia, juvenile myelomonocytic leukemia, hypereosinophilic syndrome, systemic mastocytosis, and atypical chronic myelogenous leukemia.
• C L chronic myeloid leukemia
• PV polycythemia vera
• ET essential thrombocythemia
• PMF primary or idiopathic myelofibrosis
• chronic neutrophilic leukemia chronic eosinophilic leukemia
• chronic myelomonocytic leukemia chronic myelomonocytic leukemia
• a method of treating a myeloproliferative neoplasm comprising administering to a subject in need thereof Everolimus and Compound A, or a pharmaceutically acceptable salt thereof.
• a method of treating a myeloproliferative neoplasm comprising administering to a subject in need thereof PP242 and Compound A, or a pharmaceutically acceptable salt thereof.
• the myeloproliferative neoplasm is primary myelofibrosis, post-polycythemia vera myelofibrosis or post-essential thrombocythemia myelofibrosis.
• Figures 1A - IE show the effect of selected mTOR inhibitors, a JAK1/JAK2 inhibitor, histone deacethylase inhibitors and hydroxyurea on cell apoptosis and cell cycle in SET2 or HEL cells.
• Figure 2 shows the effect of selected mTOR inhibitors, a JAK1/JAK2 inhibitor, histone deacethylase inhibitors and hydroxyurea on mTOR and JAK/STAT signaling in SET2 cells.
• Compound A provides surprising, synergistic effects for treating cancer, e.g. , myeloproliferative neoplasms (MPNs), in a subject.
• cancer e.g. , myeloproliferative neoplasms (MPNs)
• MPNs myeloproliferative neoplasms
• Such an approach - combination or co-administration of the two types of agents - can be useful for treating individuals suffering from cancer who do not respond to or are resistant to currently-available therapies.
• the combination therapy provided herein is also useful for improving the efficacy and/or reducing the side effects of currently- available cancer therapies for individuals who do respond to such therapies.
• a "combination of agents” and similar terms refer to a combination of two types of agents: (1) an mTOR inhibitor and (2) a JAK inhibitor (e.g., a JAK kinase inhibitor of the formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)).
• a JAK inhibitor e.g., a JAK kinase inhibitor of the formula I (e.g., Compound A, or a pharmaceutically acceptable salt thereof)
• mTOR The mammalian target of rapamycin, commonly known as mTOR, is a serine/threonine protein kinase that regulates cell growth, cell proliferation, cell motility, cell survival, protein synthesis, and transcription. mTOR is a key intermediary in multiple mitogenic signaling pathways and plays a central role in modulating proliferation and angiogenesis in normal tissues and neoplastic processes.
• mTOR exists within two complexes, mTORCl and mTORC2.
• mTORCl is sensitive to rapamycin analogs (such as temsirolimus or everolimus) and mTORC2 is largely rapamycin-insensitive.
• rapamycin analogs such as temsirolimus or everolimus
• mTORC2 is largely rapamycin-insensitive.
• mTOR inhibitor refers to a compound or a ligand that inhibits at least one activity of an mTOR, such as the serine/threonine protein kinase activity on at least one of its substrates (e.g., p70S6 kinase 1, 4E-BP1, AKT/PKB and eEF2).
• substrates e.g., p70S6 kinase 1, 4E-BP1, AKT/PKB and eEF2
• mTOR inhibitors include, without limitation, rapamycin (sirolimus), rapamycin derivatives, CI- 779, everolimus (CerticanTM), ABT-578, tacrolimus (FK 506), ABT-578, AP-23675, BEZ-235, OSI-027, QLT-0447, ABI-009, BC-210, salirasib, TAFA-93, deforolimus (AP-23573), temsirolimus (ToriselTM), 2-(4-Amino-1-isopropyl-1H-pyrazolo[3,4- d]pyrimidin-3-yl)-1H-indol-5-ol (PP242) and AP-23841.
• selective mTOR inhibitor refers to a compound or a ligand that inhibits mTOR activity but does not inhibit PI3K activity. Suitable selective mTOR inhibitors include RAD001. Accordingly, in one aspect, provided herein is a combination therapy comprising a selective mTOR inhibitor and a JAK inhibitor.
• Rapamycin is a known macrolide antibiotic produced by Streptomyces hygroscopicus. Suitable derivatives of rapamycin include e.g., compounds of formula II:
• R 1 aa is CH 3 or C 3-6 alkynyl
• R 2 aa is H or -CH 2 -CH 2 -OH, 3-hydroxy-2-(hydroxymethyl)-2-methyl-propanoyl or tetrazolyl, and
• X 2aa 0, (H,H) or (H,OH)
• R 2aa is -CH 2 -CH 2 -OH, e.g., a physiologically hydro lysable ether thereof.
• rapamycin derivatives of formula ⁇ are, e.g., 32-deoxorapamycin, 16-pent-2-ynyloxy-32-deoxorapamycin, 16-pent-2-ynyloxy-32(S or R)-dihydro- rapamycin, 16-pent-2-ynyloxy-32(S or R)-dihydro-40-O-(2-hydroxyethyl)-rapamycin, 40-[3-hydroxy-2-(hydroxymethyl)-2-methylpropanoate]-rapamycin (also called CCI779) or 40-epi-(tetrazolyl)-rapamycin (also called ABT578).
• Rapamycin derivatives may also include the so-called rapalogs, e.g., as disclosed in WO 98/02441 and WO 01/14387, e.g. AP23573, AP23464, AP23675 or AP23841. Further examples of a rapamycin derivative are those disclosed under the name TAFA-93 (a rapamycin prodrug), biolimus-7 or biolimus-9.
• the mTOR inhibitor used in the combination therapy provided herein is Everolimus (RAD001) or 2-(4-amino-1-isopropyl-1H-pyrazolo[3,4- d]pyrimidin-3-yl)-1H-indol-5-ol (PP242) (see, e.g., Apsel et al, Nature Chemical Biology 4, 691-699 (2008)).
• JAKl also known as Janus kinase- 1
• JAK2 also known as Janus kinase-2
• JAK3 also known as Janus kinase, leukocyte
• JAKL L-JAK and Janus kinase-3
• TYK2 also known as protein-tyrosine kinase 2
• JAK proteins range in size from 120 to 140 kDa and comprise seven conserved JAK homology (JH) domains; one of these is a functional catalytic kinase domain, and another is a pseudokinase domain potentially serving a regulatory function and/or serving as a docking site for STATs (Scott, M. J., C. J. Godshall, et al. (2002) Clin Diagn Lab Immunol 9(6): 1153-9).
• JH JAK homology
• a "JAK inhibitor” refers to a compound or a ligand that inhibits at least one activity of a JAK kinase.
• a "JAK inhibitor” can also be a "JAK1/JAK2 irjiibitor.' 1
• the JAK inhibitor induces a JAK-inhibited state.
• Examples of JAK inhibitors include compounds of formula I and AZD1480.
• R 1 , R 2 and 3 are independently selected from H, halo, and C 1-4 alkyl and Z is C 3-6 cycloalkyl (e.g., cyclopentyl).
• Examples of compounds of formula I include the compounds described in U.S. U.S. Patent No. 7,598,257, which is incorporated herein by reference in its entirety. Methods of making compounds of formula I, including Compound A, can be found in U.S. Patent No. 7,598,257 and PCT Publication WO/2010/083283
• the compound of formula I is 3-cyclopentyl-3-[4- (7H-pyrrolo[2,3-d]pyrimidm-4-yl)-1H-pyrazol-1-yl]propanenitrile or a pharmaceutically acceptable salt thereof.
• the compound of formula I is (3R)-3- cyclopentyl-3 -[4-(7H-pyrrolo [2,3 -d]pyrimidin-4-yl)- 1 H-pyrazol- 1 -yl]propanenitrile (Compound A) or a pharmaceutically acceptable salt thereof.
• the compound of formula I is (3S)-3-cyclopentyl-3-[4-(7H-pyrrolo[2,3- d]pyrimidin-4-yl)-l H-pyrazol- l-yl]propanenitrile or a pharmaceutically acceptable salt thereof.
• the synthesis of these compounds are described in, for example, U.S. Patent No. 7,598,257 and PCT Publication WO/2010/083283 (PCT/US2010/021003).
• the compound of formula I is (3R)-3 -cyclopentyl-3 -[4- (7H-pyrrolo[2,3-d]pyiimidin-4-yl)-1H-pyrazol-1-yl]propanemtrile maleic acid salt.
• the compound of formula I is (3R)-3-cyclopentyl-3-[4-(7H- pyrrolo[2,3-d]pyrimidm-4-yl)-1H-pyrazol-1-yl]propanenitrile sulfuric acid salt.
• the compound is of formula I is (3R)-3-cyclopentyl-3-[4-(7H- pyrrolo[2,3-d]pyrmiidin-4-yl)-1H-pyrazol-1-yl]propanenitrile phosphoric acid salt ("phosphoric acid salt of Compound A").
• phosphoric acid salt of Compound A The synthesis of these compounds are described in, for example, U.S. Patent Application No. 12/137,892, which is
• a combination therapy comprising the phosphoric acid salt of Compound A and an mTOR inhibitor, e.g., Everolimus or PP242.
• an mTOR inhibitor e.g., Everolimus or PP242.
• C x -C y -alkyl indicates a particular alkyl group (straight- or branched-chain) of a particular range of carbons.
• C 1 -C 4 -alkyl includes, but is not limited to, methyl, ethyl, propyl, butyl, isopropyl, tert-butyl and isobutyl.
• C 3-6 cycloalkyl refers to saturated or unsaturated monocyclic or bicyclic hydrocarbon groups of 3-6 carbon atoms, preferably 5 carbon atoms.
• exemplary monocyclic hydrocarbon groups include, but are not limited to, cyclopropyl, cyclobutyl, and cyclopentyl.
• halogen refers to chloro, bromo, fluoro, and iodo groups.
• Agents may contain one or more asymmetric elements such as stereogenic centers or stereogenic axes, e.g., asymmetric carbon atoms, so that the compounds can exist in different stereoisonieric forms. These compounds can be, for example, racemates or optically active forms. For compounds with two or more asymmetric elements, these compounds can additionally be mixtures of diastereomers. For compounds having asymmetric centers, it should be understood that all of the optical isomers and mixtures thereof are encompassed. In addition, compounds with carbon- carbon double bonds may occur in Z- and E-forms; all isomeric forms of the compounds are included in the present invention.
• the single enantiomers can be obtained by asymmetric synthesis, synthesis from optically pure precursors, or by resolution of the racemates. Resolution of the racemates can also be accomplished, for example, by conventional methods such as crystallization in the presence of a resolving agent, or chromatography, using, for example a chiral HPLC column.
• reference to compounds useful in the combination therapy of the invention includes both the free base of the compounds, and all pharmaceutically acceptable salts of the compounds.
• the term "pharmaceutically acceptable salts” refers to the nontoxic acid or alkaline earth metal salts of the pyrimidine compounds of the invention. These salts can be prepared in situ during the final isolation and purification of the pyrimidine compounds, or by separately reacting the base or acid functions with a suitable organic or inorganic acid or base, respectively.
• Representative salts include, but are not limited to, the following: acetate, adipate, alginate, citrate, aspartate, benzoate, benzenesulfonate, bisulfate, butyrate, camphorate, camphorsulfonate, digluconate, cyclopentanepropionate, dodecylsulfate, ethanesulfonate, glucoheptanoate,
• glycerophosphate hemi-sulfate, heptanoate, hexanoate, fumarate, hydrochloride, hydrobromide, hydroiodide, 2-hydroxyethanesulfonate, lactate, maleate,
• methanesulfonate nicotinate, 2-naphth-alenesulfonate, oxalate, pamoate, pectinate, persulfate, 3-phenylproionate, picrate, pivalate, propionate, succinate, sulfate, tartrate, thiocyanate, p-toluenesulfonate, and undecanoate.
• the basic nitrogen-containing groups can be quaternized with such agents as alkyl halides, such as methyl, ethyl, propyl, and butyl chloride, bromides, and iodides; dialkyl sulfates like dimethyl, diethyl, dibutyl, and diamyl sulfates, long chain halides such as decyl, lauryl, myristyl, and stearyl chlorides, bromides and iodides, aralkyl halides like benzyl and phenethyl bromides, and others. Water or oil-soluble or dispersible products are thereby obtained.
• alkyl halides such as methyl, ethyl, propyl, and butyl chloride, bromides, and iodides
• dialkyl sulfates like dimethyl, diethyl, dibutyl, and diamyl sulfates
• long chain halides such as
• inorganic acids as hydrochloric acid, hydroboric acid, nitric acid, sulfuric acid and phosphoric acid
• organic acids as formic acid, acetic acid, trifluoroacetic acid, fumaric acid, tartaric acid, oxalic acid, maleic acid, methanesulfonic acid, succinic acid, malic
• a combination therapy comprising an mTOR inhibitor and a JAK inhibitor (e.g., the JAK inhibitor of formula I (e.g., Compound A, or a
• Administration of the combination includes administration of the combination in a single formulation or unit dosage form, administration of the individual agents of the combination concurrently but separately, or administration of the individual agents of the combination sequentially by any suitable route.
• the dosage of the individual agents of the combination may require more frequent administration of one of the agent(s) as compared to the other agent(s) in the combination. Therefore, to permit appropriate dosing, packaged pharmaceutical products may contain one or more dosage forms that contain the combination of agents, and one or more dosage forms that contain one of the combination of agents, but not the other agent(s) of the combination.
• single formulation refers to a single carrier or vehicle formulated to deliver effective amounts of both therapeutic agents to a patient.
• the single vehicle is designed to deliver an effective amount of each of the agents, along with any pharmaceutically acceptable carriers or excipients.
• the vehicle is a tablet, capsule, pill, or a patch. In other embodiments, the vehicle is a solution or a suspension.
• unit dose is used herein to mean simultaneous administration of both agents together, in one dosage form, to the patient being treated.
• the unit dose is a single formulation.
• the unit dose includes one or more vehicles such that each vehicle includes an effective amount of at least one of the agents along with pharmaceutically acceptable carriers and excipients.
• the unit dose is one or more tablets, capsules, pills, or patches administered to the patient at the same time.
• treat is used herein to mean to relieve, reduce or alleviate, at least one symptom of a disease in a subject.
• the term “treat” also denotes, to arrest, delay the onset (i.e., the period prior to clinical manifestation of a disease or symptom of a disease) and/or reduce the risk of developing or worsening a symptom of a disease.
• subject is intended to include animals. Examples of subjects include mammals, e.g., humans, dogs, cows, horses, pigs, sheep, goats, cats, mice, rabbits, rats, and transgenic non-human animals.
• the subject is a human, e.g., a human suffering from, at risk of suffering from, or potentially capable of suffering from cancer, e.g. , myeloproliferative neoplasms.
• the term “about” or “approximately” usually means within 20%, more preferably within 10%, and most preferably still within 5% of a given value or range. Alternatively, especially in biological systems, the term “about” means within about a log (i. e., an order of magnitude) preferably within a factor of two of a given value.
• combination therapy refers to the administration of two or more therapeutic agents to treat a therapeutic condition or disorder described in the present disclosure.
• administration encompasses co-administration of these therapeutic agents in a substantially simultaneous manner, such as in a single capsule having a fixed ratio of active ingredients or in multiple, or in separate containers (e.g., capsules) for each active ingredient.
• administration also encompasses use of each type of therapeutic agent in a sequential manner, either at approximately the same time or at different times.
• the treatment regimen will provide beneficial effects of the drug combination in treating the conditions or disorders described herein.
• the combination of agents described herein display a synergistic effect.
• the terra "synergistic effect" as used herein, refers to action of two agents such as, for example, an mTOR inhibitor and a JAK inhibitor (e.g., a JAK inhibitor of formula I), producing an effect, for example, slowing the symptomatic progression of cancer or symptoms thereof, which is greater than the simple addition of the effects of each drug administered by themselves.
• a synergistic effect can be calculated, for example, using suitable methods such as the Sigmoid-Emax equation (Holford, N. H. G. and Scheiner, L. B., Clin. Pharmacokinet. 6: 429-453 (1981)), the equation of Loewe additivity (Loewe, S. and Muischnek, H., Arch. Exp. Pathol Pharmacol. 114: 313-326 (1926)) and the median-effect equation (Chou, T. C. and Talalay, P., Adv. Enzyme Regul. 22: 27-55
• a combination therapy comprising an effective amount of a JAK inhibitor and an mTOR inhibitor.
• An "effective amount" of a combination of agents i.e., an mTOR inhibitor and a JAK inhibitor (e.g., a JAK inhibitor of formula I) is an amount sufficient to provide an observable improvement over the baseline clinically observable signs and symptoms of the disorders treated with the combination.
• oral dosage form includes a unit dosage form prescribed or intended for oral administration.
• the invention provides a method of treating JAK-associated diseases, e.g., cancer, e.g., myeloproliferative neoplasms, in an individual by administering to the individual a combination of an mTOR inhibitor and a JAK inhibitor (e.g., a JAK inhibitor of formula I).
• JAK-associated diseases e.g., cancer, e.g., myeloproliferative neoplasms
• a JAK-associated disease can include any disease, disorder or condition that is directly or indirectly linked to expression or activity of the JAK, including over-expression and/or abnormal activity levels.
• a JAK-associated disease can also include any disease, disorder or condition that can be prevented, ameliorated, or cured by modulating JAK activity.
• JAK-associated diseases include diseases involving the immune system including, for example, organ transplant rejection ⁇ e.g. , allograft rejection and graft versus host disease).
• JAK-associated diseases include autoimmune diseases such as multiple sclerosis, rheumatoid arthritis, juvenile arthritis, type I diabetes, lupus, psoriasis, inflammatory bowel disease, ulcerative colitis, Crohn's disease, myasthenia gravis, immunoglobulin nephropathies, autoimmune thyroid disorders, and the like.
• the autoimmune disease is an autoimmune bullous skin disorder such as pemphigus vulgaris (PV) or bullous pemphigoid (BP).
• JAK-associated diseases include allergic conditions such as asthma, food allergies, atopic dermatitis and rhinitis.
• Further examples of JAK- associated diseases include viral diseases such as Epstein Barr Virus (EBV), Hepatitis B, Hepatitis C, HIV, HTLV 1, Varicella-Zoster Virus (VZV) and Human Papilloma Virus (HPV).
• EBV Epstein Barr Virus
• HBV Human Papilloma Virus
• HPV Human Papilloma Virus
• JAK-associated diseases or conditions include skin disorders such as psoriasis (for example, psoriasis vulgaris), atopic dermatitis, skin rash, skin irritation, skin sensitization (e.g., contact dermatitis or allergic contact dermatitis).
• skin disorders such as psoriasis (for example, psoriasis vulgaris), atopic dermatitis, skin rash, skin irritation, skin sensitization (e.g., contact dermatitis or allergic contact dermatitis).
• certain substances including some pharmaceuticals when topically applied can cause skin sensitization.
• the skin disorder is treated by topical administration of the combination therapy.
• the JAK-associated disease is cancer including those characterized by solid tumors (e.g., prostate cancer, renal cancer, hepatic cancer, pancreatic cancer, gastric cancer, breast cancer, lung cancer, cancers of the head and neck, thyroid cancer, glioblastoma, Kaposi's sarcoma, Castleman's disease, melanoma etc.), hematological cancers (e.g., lymphoma, leukemia such as acute lymphoblastic leukemia, or multiple myeloma), and skin cancer such as cutaneous T-cell lymphoma (CTCL) and cutaneous B-cell lymphoma.
• CTCL cutaneous T-cell lymphoma
• Example cutaneous T-cell lymphomas include Sezary syndrome and mycosis fungoides.
• JAK-associated diseases can further include those characterized by expression of a mutant JAK2 such as those having at least one mutation in the pseudo-kinase domain (e.g., JAK2V617F).
• JAK-associated diseases can further include myeloproliferative disorders (MPDs) such as polycythemia vera (PV), essential thrombocythemia (ET), myeloid metaplasia with myelofibrosis (MMM), chronic myelogenous leukemia (CML), chronic myelomonocytic leukemia (CMML), hypereosinophilic syndrome (HES), systemic mast cell disease (SMCD), and the like.
• MPDs myeloproliferative disorders
• PV polycythemia vera
• ET essential thrombocythemia
• MMM myeloid metaplasia with myelofibrosis
• CML chronic myelogenous leukemia
• CMML chronic myelomonocytic leukemia
• HES hypereosinophilic syndrome
• SMCD systemic mast cell disease
• JAK-associated diseases include inflammation and inflammatory diseases.
• Example inflammatory diseases include inflammatory diseases of the eye (e.g., ulceris, uveitis, scleritis, conjunctivitis, or related disease), inflammatory diseases of the respiratory tract (e.g., the upper respiratory tract including the nose and sinuses such as rhinitis or sinusitis or the lower respiratory tract including bronchitis, chronic obstructive pulmonary disease, and the like), inflammatory myopathy such as myocarditis, and other inflammatory diseases.
• the combination therapy described herein can further be used to treat ischemia reperfusion injuries or a disease or condition related to an inflammatory ischemic event such as stroke or cardiac arrest.
• the combination therapy described herein can further be used to treat anorexia, cachexia, or fatigue such as that resulting from or associated with cancer.
• the combination therapy described herein can further be used to treat restenosis, sclerodermitis, or fibrosis.
• the combination therapy described herein can further be used to treat conditions associated with hypoxia or astrogliosis such as, for example, diabetic retinopathy, cancer, or neurodegeneration. See, e.g., Dudley, A. C. et al. Biochem. J. 2005, 390(Pt 2):427-36 and Sriram, K. et al. J. Biol. Chem. 2004, 279(19): 19936-47. Epub 2004 Mar 2.
• the chronic myeloproliferative neoplasms which include polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF), are characterized by a V617F point mutation in exon 14 of Janus Kinase 2 (JAK2) occurring in greater than 95% of PV and 60% of ET or PMF patients.
• JAK2 exon 12 mutations are detected in rare patients with PV while mutations in MPL have been reported in 5-10% of ET or PMF patients (Vannucchi AM, Guglielmelli, P, Tefferi, A. Advances in understanding and management of myeloproliferative neoplasms. AC- A Cancer Journal for Clinicians.
• JAK2 represents a potentially valuable therapeutic target in MPN patients (Id.), as supported by effects in murine models of MPN and current evidence in clinical trials.
• PI3K phosphatidylinositol 3- kinase
• ERK extracellular signal-regulated kinase
• Akt resulted constitutively activated in JAK2W617F mutated cells in vitro and in V617F transgenic or knock-in mice (Akada H, Yan D, Zou H, Fiering S, Hutchison RE, Mohi MG.
• Conditional expression of heterozygous or homozygous Jak2V617F from its endogenous promoter induces a polycythemia vera-like disease. Blood.
• Akt is phosphorylated and activated via PI3K in response to ligand-engagement of the erythropoietin (EPO) receptor and has a role in normal erythroid differentiation.
• EPO erythropoietin
• Akt is able to support erythroid differentiation in JAK2-deficient fetal liver progenitor cells through a mechanism downstream of EpoR and at least in part related to GATA-1 phosphorylation.
• Akt resulted activated in erythroblasts from the bone marrow or the spleen of mice with conditional JAK2V617 ⁇ knock-in allele, especially in V617F homozygous animals. Comparably increased phosphorylation of STAT5 and Akt was demonstrated by immunocytochemistry in the bone marrow of MPN patients, particularly in
• the cancer that can be treated using the combination provided herein is a myeloproliferative disorder.
• Myeloproliferative disorders (MPDs), now commonly referred to as meyloproliferative neoplasms (MPNs), are in the class of haematological malignancies that are clonal disorders of
• hematopoietic progenitors Tefferi, A. and Vardiman, J. W., Classification and diagnosis of myeloproliferative neoplasms: The 2008 World Health Organization criteria and point-of-care diagnostic algorithms, Leukemia, September 2007, 22: 14-22, is hereby incorporated by reference. They are characterized by enhanced proliferation and survival of one or more mature myeloid lineage cell types.
• This category includes but is not limited to, chronic myeloid leukemia (CML), polycythemia vera (PV), essential thrombocythemia (ET), primary or idiopathic myelofibrosis (PMF), chronic neutrophilic leukemia, chronic eosinophilic leukemia, chronic myelomonocytic leukemia, juvenile myelomonocytic leukemia, hypereosinophilic syndrome, systemic mastocytosis, and atypical chronic myelogenous leukemia. Tefferi, A. and Gilliland, D. G., Oncogenes in myeloproliferative disorders, Cell Cycle. March 2007, 6(5): 550-566 is hereby fully incorporated by reference in its entirety for all purposes.
• the combination therapy provided herein is useful for the treatment of primary myelofibrosis, post-polycythemia vera myelofibrosis, post-essential thrombocythemia myelofibrosis, and secondary acute myelogenous leukemia.
• the combination therapy provided herein can be used to treat patients with intermediate or high-risk myelofibrosis, including primary
• myelofibrosis post-polycythemia vera myelofibrosis and post-essential
• the subject to be treated e.g., a human
• the subject to be treated is determined to be non-responsive or resistant to one or more therapies for myeloproliferative disorders.
• myeloproliferative neoplasm in a subject in need thereof, comprising administering to the subject an effective amount of a composition comprising Everolimus and Compound A, or a pharmaceutically acceptable salt thereof.
• a myeloproliferative disorder e.g., intermediate or high-risk myelofibrosis, including primary myelofibrosis, post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis.
• provided herein is a method of treating a
• myeloproliferative neoplasm in a subject in need thereof comprising administering to the subject an effective amount of a composition comprising PP242 and Compound A, or a pharmaceutically acceptable salt thereof.
• a myeloproliferative disorder by administering an effective amount of a compound of an mTOR inhibitor and a JAK inhibitor to an individual suffering from a disease.
• the amount of the combination of agents is effective to treat the disease. It is important to note the synergistic effects of the combination of agents: even though one or more of the agents administered alone at a particular dosage may not be effective, when administered in combination, at the same dosage of each agent, the treatment is effective.
• the doses of the one or more of the agents in the combination therefore can be less than the FDA approved doses of each agent.
• the optimal dose of the combination of agents for treatment of disease can be determined empirically for each individual using known methods and will depend upon a variety of factors, including, though not limited to, the degree of advancement of the disease; the age, body weight, general health, gender and diet of the individual; the time and route of administration; and other medications the individual is taking. Optimal dosages may be established using routine testing and procedures that are well known in the art.
• the amount of combination of agents that may be combined with the carrier materials to produce a single dosage form will vary depending upon the individual treated and the particular mode of administration.
• the unit dosage forms containing the combination of agents as described herein will contain the amounts of each agent of the combination that are typically administered when the agents are administered alone. Frequency of dosage may vary depending on the compound used and the particular condition to be treated or prevented. In general, the use of the minimum dosage that is sufficient to provide effective therapy is preferred. Patients may generally be monitored for therapeutic effectiveness using assays suitable for the condition being treated or prevented, which will be familiar to those of ordinary skill in the art.
• the dosage form can be prepared by various conventional mixing, conimmution and fabrication techniques readily apparent to those skilled in the chemistry of drug formulations.
• the oral dosage form containing the combination of agents or individual agents of the combination of agents may be in the form of micro-tablets enclosed inside a capsule, e.g. a gelatin capsule.
• a gelatin capsule as is employed in
• compositions can be used, such as the hard gelatin capsule known as CAPSUGEL, available from Pfizer.
• oral dosage forms useful herein contain the combination of agents or individual agents of the combination of agents in the form of particles.
• Such particles may be compressed into a tablet, present in a core element of a coated dosage form, such as a taste-masked dosage form, a press coated dosage form, or an enteric coated dosage form, or may be contained in a capsule, osmotic pump dosage form, or other dosage form.
• the drug compounds of the present invention are present in the combinations, dosage forms, pharmaceutical compositions and pharmaceutical formulations disclosed herein in a ratio in the range of 100:1 to 1:100.
• the ratio of a compound of formula I : an mTOR inhibitor can be in the range of 1:100 to 1:1, for example, 1 :100, 1:90, 1:80, 1:70, 1:60, 1 :50, 1:40, 1 :30, 1:20, 1: 10, 1:5, 1:2, or 1:1 of formula I : an mTOR inhibitor.
• the ratio of an mTOR inhibitor : a compound of formula I can be in the range of 1 : 100 to 1:1, for example, 1:100, 1 :90, 1:80, 1:70, 1:60, 1:50, 1:40, 1:30, 1:20, 1:10, 1:5, 1:2, or 1:1 of an mTOR inhibitor : a compound of formula I.
• the optimum ratios, individual and combined dosages, and concentrations of the drug compounds that yield efficacy without toxicity are based on the kinetics of the active ingredients' availability to target sites, and are determined using methods known to those of skill in the art.
• the pharmaceutical compositions or combinations provided herein i.e., an mTOR inhibitor and a JAK inhibitor (e.g., a JAK inhibitor of formula I)
• Suitable clinical studies may be, for example, open label, dose escalation studies in patients with proliferative diseases. Such studies prove in particular the synergism of the active ingredients of the combination of the invention.
• the beneficial effects on proliferative diseases may be determined directly through the results of these studies which are known as such to a person skilled in the art.
• Such studies may be, in particular, suitable to compare the effects of a monotherapy using the active ingredients and a combination of the invention.
• the dose of a compound of an mTOR inhibitor e.g., Everolimus (RAD001) or PP242
• a JAK inhibitor e.g., a JAK inhibitor of formula I
• a JAK inhibitor may be administered in a fixed dose and the dose of the mTOR inhibitor may be escalated.
• Each patient may receive doses of the compounds either daily or intermittently.
• the efficacy of the treatment may be determined in such studies, e.g., after 12, 18 or 24 weeks by evaluation of symptom scores every 6 weeks.
• a combination therapy of the invention may result not only in a beneficial effect, e.g. a synergistic therapeutic effect, e.g. with regard to alleviating, delaying progression of or inhibiting the symptoms, but also in further surprising beneficial effects, e.g. fewer side-effects, an improved quality of life or a decreased morbidity, compared with a monotherapy applying only one of the pharmaceutically active ingredients used in the combination of the invention.
• a beneficial effect e.g. a synergistic therapeutic effect, e.g. with regard to alleviating, delaying progression of or inhibiting the symptoms
• further surprising beneficial effects e.g. fewer side-effects, an improved quality of life or a decreased morbidity
• a further benefit may be that lower doses of the active ingredients of the combination of the invention may be used, for example, that the dosages need not only often be smaller but may also be applied less frequently, which may diminish the incidence or severity of side-effects. This is in accordance with the desires and requirements of the patients to be treated.
• a pharmaceutical composition comprising a quantity, which may be jointly therapeutically effective at targeting or preventing cancer, e.g., a myeloproliferative disorder.
• an mTOR inhibitor and a JAK inhibitor e.g., a JAK inhibitor of formula I
• the unit dosage form may also be a fixed combination.
• compositions for separate administration of both compounds, or for the administration in a fixed combination i.e. a single galenical composition comprising both compounds according to the invention may 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 humans, comprising a therapeutically effective amount of at least one pharmacologically active combination partner alone, e.g. as indicated above, or in combination with one or more
• the drug combinations provided herein may be formulated by a variety of methods apparent to those of skill in the art of pharmaceutical formulation.
• the various release properties described above may be achieved in a variety of different ways.
• Suitable formulations include, for example, tablets, capsules, press coat formulations, and other easily administered formulations.
• Suitable pharmaceutical formulations may contain, for example, from about 0.1 % to about 99.9%, preferably from about 1 % to about 60 %, of the active ingredient(s).
• Pharmaceutical formulations for the combination therapy for enteral or parenteral administration are, for example, those in unit dosage forms, such as sugar- coated tablets, tablets, capsules or suppositories, or ampoules. If not indicated otherwise, these are prepared in a manner known per se, for example by means of conventional mixing, granulating, sugar-coating, dissolving or lyophilizing processes. It will be appreciated that the unit content of a combination partner contained in an individual dose of each dosage form need not in itself constitute an effective amount since the necessary effective amount may be reached by administration of a plurality of dosage units.
• a therapeutically effective amount of each of the combination partner 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.
• the method of treating a disease according to the invention may comprise (i) administration of the first agent in free or pharmaceutically acceptable salt form and (ii) administration of the second agent in free or
• administering also encompasses the use of a pro-drug of a combination partner that convert in vivo to the combination partner as such.
• the instant invention is therefore to be understood as embracing all such regimens of simultaneous or alternating treatment and the term "administering" is to be interpreted accordingly.
• each of the combination partners employed in the combination of the invention may vary depending on the particular compound or pharmaceutical composition employed, the mode of administration, the condition being treated, the severity of the condition being treated.
• the dosage regimen of 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 clinician or physician of ordinary skill can readily determine and prescribe the effective amount of the single active ingredients required to alleviate, counter or arrest the progress of the condition.
• Preferred suitable dosages for the compounds used in the treatment described herein are on the order of about 1 mg to about 600 mg, preferably about 3, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 90, 95, 100, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320, 340, 360, 380, 400, 420, 440, 460, 480, 500, 520, 540, 560, 580 to about 600 mgs total.
• the JAK inhibitor is administered in a 5mg, lOmg, 15mg, 20mg, or a 25mg dose.
• a composition comprising an mTOR inhibitor and a compound of formula I.
• the compound of formula I is (3R)-3-cyclopentyl-3-[4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1- yl]propanenitrile, or a pharmaceutically acceptable salt thereof.
• the mTOR inhibitor is Everolimus (RAD001) or 2-(4-Amino-1-isopropyl-1H- pyrazolo[3,4-d]pyrimidin-3-yl)-1H-indol-5-ol (PP242).
• the composition further comprises a pharmaceutically acceptable carrier.
• RAD001 an mTOR specific allosteric inhibitor
• PP242 an ATP domain inhibitor of mTOR
• hydroxyurea was obtained from Sigma-Aldrich (St. Louis, Germany).
• Interferon-a was obtained from Pegasys.
• Antibodies against phospho(p)- STAT5 (Tyr694), STAT5, p-4EBPl (Thr70), 4EBP1, mTOR, p-JAK2 (Tyrl 007/1008) and JAK2, were from Cell Signaling Technology (Danvers, MA, US).
• Anti-human tubulin antibody was from Santa Cruz Biotechnology (Santa Cruz, CA, US).
• siRNAs against mTOR were from Dharmacon siGENOME Smart pool (Thermo Scientific, Waltham, MA, US); the siGENOME Non- Targeting siRNA Pool#l (Thermo Scientific) was used as a negative control.
• the HEL, SET2 and K562 human cell lines were purchased from the German Collection of Microorganisms and Cell Cultures (DSMZ, Braunschweig, Germany).
• Murine BaF/3 and BaF/3-EPOR cells expressing JAK2 wild-type (wt) orJ4iC2V617F were donated by R. Skoda (Basel, Switzerland).
• Cell lines were cultured in RPMI 1640 supplemented with 10% fetal bovine serum (FBS; Lonza, Belgium) (20% for SET2 cells), antibiotics and I ⁇ glutamine.
• mIL-3 and EPO were added to the culture medium of JAK2 WT BaF/3 and BaF/3-EPOR cells, respectively.
• PB peripheral blood
• BM bone marrow
• JAK2 ⁇ 6 ⁇ TF mutational status was determined by a quantitative real-time PCR assay in granulocytes. Inhibition of proliferation assay, clonogenic assay, and apoptosis or cell cycle analysis
• Cells (2 l0 4 ) were plated in 96-well culture tissue plates with increasing concentrations of the drug(s), in triplicate; viable cells were assessed using the WST-1 assay (Roche, USA) and normalized to wells containing an equivalent volume of vehicle (DMSO) only. The concentration at which 50% inhibition of proliferation occurred (IC50) was calculated using the Origin software (V 7.5, OriginLab Northampton, MA). In some experiments, clonogenic tests were also employed. Cells (5xl0 3 ) were plated in 0.5% agar in medium supplemented with FBS, and variable amount of the drug(s) (or an equivalent volume of vehicle in control plates) was added once at the beginning of culture. Colonies were enumerated by inverted microscopy after 7 day incubation.
• Annexin-V-FLUOS Staining kit (Roche); at least 20,000 events were acquired.
• lxlO 6 cells were treated with ethanol 95%, RNase 10 ⁇ g/mL and propidium iodide 50 mg/mL.
• BM mononuclear cells from MPN patients or control subjects were plated at lxl0 5 /mL in methylcellulose (MethoCult; StemCell Technologies, Vancouver, Canada) supplemented with SCF 50ng/mL, IL-3 lOng mL, IL-6 lOng/mL, GM-CSF lOng/mL, G-CSF 1 Ong/mL and EPO 3U/mL for the growth of BFU-E and CFU-GM.
• EEC assay was performed by plating 2.5x10 5 /mL PB mononuclear cells from PV patients in methylcellulose containing leukocyte-conditioned medium without EPO (StemCell Techno!., cat. No.#04531).
• CD34 + cells were plated in a 24- ell plate in Megacult Collagen and medium with lipids (StemCell Technol.) supplemented with Thrombopoietin 50ng/mL, IL-3 lOng mL, IL-6 lOng/mL. Colonies were enumerated on day 14 according to standard criteria.
• RNA isolation and Real-Time quantitative PCR (RTQ-PCR)
• Exponentially growing HEL cells were electroporated with siRNAs in the Amaxa Nucleofector (Amaxa Biosystems, Gaithersburg, MD, USA) using Amaxa kit R. Briefly, 2-5xl0 6 cells in 0.1 mL volume were transfected with 1 ⁇ siRNA and immediately transferred to 24-well plates containing prewarmed culture medium.
• JAK2V617F mutant human leukemia cell lines were sensitive to mTOR inhibition, the selective allosteric mTOR inhibitor RADOOl and the ATP competitive inhibitor of the active site of mTOR, PP242, were empolyed. It was discovered that JAK2V6HF mutant HEL and SET2 cells were at least as sensitive to mTOR inhibition as the BCR/ABL positive K562 cells used as control.IC 5 o values are shown in Table 1. The effects of mTOR inhibitors in JAK2 wild-type murine Independent (Ba/F3) or EPO-dependent (Ba/F3-EPOR) cells or the cytokine-independent JAK2V611F counterpart were investigated.
• Ba/F3 murine Independent
• EPO-dependent Ba/F3-EPOR
• V617F Ba/F3 cells were more sensitive to RADOOl than the JAK2 wt counterpart either in the absence or the presence of IL-3 in the culture medium.
• the IC 5 o of V617F mutant cells was 651nM and 1,213nM in the absence and presence of EPO, respectively, compared to an IC50 > 10,000 nM in JAK2 wt cells.
• PP242 was similarly effective: in V617F Ba/F3 cells IC 50 was 800nM and 1,600nM, respectively, in the absence or presence of IL-3 versus 3,400nM in wt cells; in wt Ba F3-EPOR cells, IC 50 was 5,93 lnM versus 500nM and 750nM in V617F cells supplemented or not with EPO, respectively (Table 1). At their IC50 concentration, RAD001 and PP242 (not shown) caused cell cycle arrest of SET2 and HEL cells in the G0/G1 phase of the cell cycle ( Figure 1 A).
• HEL histone deacethylase
• Figure 1 shows the effect of selected mTOR inhibitors, a JAK1/JAK2 inhibitor, histone deacethylase inhibitors and hydroxyurea on cell apoptosis and cell cycle in SET2 or HEL cells.
• panels (B) to (E) the percentage of Annexin V-positive apoptotic cells was measured by flow cytometry in SET2 cells that had been exposed for 48h to varying amount of the mTOR inhibitors RAD001 or PP242 (B), JAK1/JAK2 inhibitor
• Table 4 shows inhibition of clonogenic growth of JAK2V617F mutant cell lines by mTOR inhibitors, RAD001 or PP242 and JAK1/JAK2 inhibitor Compound A.
• JAK2V617F mutant human-origin cell lines either heterozygous (SET-2) or
• HEL homozygous
• PP242 BCR/ABL mutant K562 cell line
• 10 3 cells were plated in agar in the presence of variable amount of the drug; colonies were counted on day 7 and expressed as a percentage of colony number grown in control plates containing vehicle.
• Murine BaF/3 cells over-expressing JAK2V61TF were similarly exposed to RADOO 1, PP242 or Compound A, and compared to wild-type cells (wt).
• Interleukin-3 (10 ng/mL) was added or not to the culture medium.
• IC50 values shown are the Mean ⁇ SD of at least three independent experiments. mTOR inhibitors attenuate downstream signalling of mTOR pathway and reduce STAT5 phosphorylation in Z4JE2V617F mutated cell lines
• mTOR was silenced with specific siRNA in HEL cells.
• siRNAs treatment decreased mTOR levels by only 50-60% at 24 h, the level of phosphorylated 4E-BP1 decreased dramatically compared to cells that had been treated with irrelevant control siRNA; total 4E-BP1 protein content did not change at all (data not shown).
• both mTOR and phosphorylated 4E-BP1 were barely detectable.
• the level of phosphorylated STAT5 appeared markedly reduced at 24-48 h in cells that had been nucleofected with mTOR specific siRNA compared to control; total STAT5 concent did not change.
• Figure 2 shows the effect of selected mTOR inhibitors, a JAK1/JAK2 inhibitor, histone deacethylase inhibitors and hydroxyurea on mTOR and JAK/STAT signaling in SET2 cells.
• SET2 cells were incubated for 24 h with increasing concentrations of the drugs, and the level of total and phosphorylated JAK2, STAT5, and 4EBP1 was analyzed by western blot. Tubulin was used for loading normalization. The results shown are representative of two to four similar experiments for the different drugs.
• PBMC from patients with PV were incubated with increasing concentration of RADOO 1 , PP242, Compound A or a combination of RADOOl or PP242 and Compound A in an EEC assay.
• Peripheral-blood derived mononuclear cells from PV patients were cultured in EPO-free methylcellulose medium for EEC growth, in the absence or the presence of a fixed amount of RADOOl, PP242, and/or Compound A.
• the EEC were scored at 12 day and expressed as percent of the number of colonies measured in control plates containing vehicle only. *, P ⁇ 0.05, **, PO.01.
• the results set forth in Table 6 show CIs of 0.2 and 0.26 in these cultures, further demonstrating synergism between mTOR and JAK inhibitors in the inhibition of JAK2V617F cell growth.
• JAK2 inhibitors reduce the proliferation of JAK2V61TF mutant cells in vitro, mitigate myeloproliferation in JAK2W617F transgenic animals (Liu PC, Caulder E, Li J, et al. Combined inhibition of Janus kinase 1/2 for the treatment of JAK2V617F -driven neoplasms: selective effects on mutant cells and improvements in measures of disease severity. Clin Cancer Res. 2009;15:6891-6900) and produce measurable clinical improvement in patients with myelofibrosis (V horrovsek S,
• panobinostat and the JAK2 inhibitor TG101209 determined greater attenuation of JAK/STAT signaling in human and murine .
• rapamycin a key downstream target of the PI3k/Akt pathway.
• the serine/threonine kinase mTOR functions as a central regulator of cell metabolism, survival, growth, proliferation and autophagy.
• mTOR is inhibited by a family of molecules, named rapalogs following its founding member rapamycin, that have been recently employed in clinical trials in cancers.
• mTOR exists in two complexes, TORC1 and TORC2.
• TORC1 formed with raptor, controls the level of cap-dependent mRNA translation and phosphorylates effectors such as the eukaryotic initiation factor 4E-binding protein 1 (4E-BP1) and S6 kinase 1 (S6K1).
• E-BP1 eukaryotic initiation factor 4E-binding protein 1
• S6K1 S6 kinase 1
• phosphorylated 4E-BP1 leads to inhibited binding to eukaryotic initiation factor 4E (eIF4E) and prevents translation activation of several genes, including cyclin Dl, Bcl-2, BC1-XL, and vascular endothelial growth factor.
• S6K1 regulates cell growth by phosphorylating key targets such as eIFe4, mTOR, eukaryotic initiation factor 4B and elongation-2 kinase. Both eIF4E and SKI have been involved in cellular transformation and are overexpressed in some poor- prognosis cancers. Additional components of TORC1 include mammalian LST8/G- protein ⁇ -subunit like protein (mLST8/GpL) and the recently identified partners PRAS40 and DEPTOR.
• mLST8/GpL mammalian LST8/G- protein ⁇ -subunit like protein
• mTOR also combines with Rictor in mTORC2, that is largely rapamicin insensitive, and is composed of GPL and mammalian stress-activated protein kinase interacting protein 1 (mSINl); TORC 2 is involved in the phosphorylation of Akt at Ser473.
• This negative feedback loop from mTORC2 to Akt may, in some instances, result in exacerbated tumor progression, although RAD001 was reported to potently inhibited Akt activity in leukemic cells via suppression of both mTORCl and mTORC2.
• RADOOl and PP242 were used to explore in vitro the putative role mTOR as target for therapy in MPN.
• mTOR inhibitors prompted an arrest of cell proliferation of JAK2V617F mutated human and murine leukemia cell lines at drug concentrations significantly lower than control cells (Table 1).
• RADOOl did not induce cell death while PP242 cause some cell apoptosis as highest concentrations; thus, in these experimental settings, mTOR inhibitors are mainly cytostatic. This mode of action differed from the JAK1/JAK2 inhibitor Compound A and HDAC inhibitor panobinostat that all potently induced cell apoptosis (Figure 1).
• phosphorylation can be affected by targeting JAK2- and mTOR-initiated signaling.
• rapamycin-sensitive activation of STAT3 via receptor tyrosine can be affected by targeting JAK2- and mTOR-initiated signaling.
• the IC 5 o value was calculated in proliferation inhibition assay in the presence of different drug combinations. Reported is the median Revalue from at least 3 experiments of the drugs used in combination.
• the Combination Index (CI) was calculated according to Chou and Talaly as described in Materials and Methods. A CI ⁇ 1 indicates that the interaction of the two drugs is synergistic.
• the first two columns (in gray) report, for convenience, the IC50 value of the individual drugs as calculated from data in Table 1.
• the ICso value (i.e., the concentration of drug that reduced colony number to 50% that measured in control dishes with vehicle only) was calculated in agar clonogenic assay by enumerating the colonies on day 7 in the presence of different drug concentrations.
• the control cell line was K562
• the reference were Ba/F3 wild-type cells maintained in the presence of IL-3. **, P ⁇ 0.01.
• the IC50 value was calculated in clonogenic assay in agar by enumerating the colonies grown on day 7 of culture established in the presence of different drug combinations. Reported is the median value from at least 3 experiments of IC50 of the two drugs used in combination.
• the Combination Index (CI) was calculated as described in Materials and Methods. A a CI ⁇ 1 indicates that the interaction of the two drugs is synergistic. The first two columns (in gray) indicate the IC50 value calculated for the individual drugs and are reported here from Table 4 for convenience. Table 6. Combination of AD001 or PP242 and INC242 results in synergistic activity in inhibition of clonogenic potential of human Peripheral Blood mononuclear cells from PV patients.
• the IC 50 value was calculated in clonogenic assay in agar by enumerating the colonies grown on day 7 of culture established in the presence of different drug combinations.
• the Combination Index (CI) was calculated as described in Materials and Methods. A a CI ⁇ 1 indicates that the interaction of the two drugs is synergistic.

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