WO2012121957A1

WO2012121957A1 - Combination

Info

Publication number: WO2012121957A1
Application number: PCT/US2012/027173
Authority: WO
Inventors: Andres BRAINSKY
Original assignee: GlaxoSmithKline LLC
Current assignee: GlaxoSmithKline LLC
Priority date: 2011-03-08
Filing date: 2012-03-01
Publication date: 2012-09-13
Anticipated expiration: 2013-09-08

Abstract

The present invention relates to a method of treating thrombocytopenia and/or treating transplantation rejection in a human and to pharmaceutical combinations useful in such treatment. In particular, the method relates to a treatment method that includes administering tacrolimus, and 3'-[(2Z)-[1-(3,4-dimethylphenyl)-1,5-dihydro-3-methyl-5-oxo- 4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy-[1, 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt, to a human in need thereof.

Description

COMBINATION

FIELD OF THE INVENTION The present invention relates to a method of treating thrombocytopenia in a mammal, suitably a human, and to combinations useful in such treatment. In particular, the method relates to a novel combination comprising tacrolimus: 3S- [3R^*[E(1 S\3S\4S^*)],4S^*,5R\8S^*,9E, 12R^*, 14R^*.15S^*, 16R^*, 18S^*, 19S^*,26aR^*

-5,6,8, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19,24,25,26,26a-hexadecahydro-5, 19-dihydroxy

-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1 -methylethenyl]-14, 16-dimethoxy

-4,10, 12, 18-tetramethyl-8-(2-propenyl)-15,19-epoxy-3H-pyrido[2, 1 -c] [1 ,4]

oxaazacyclotricosine-1 ,7,20,21 (4H,23H)tetrone monohydrate, or a pharmaceutically acceptable salt thereof, and the TPO receptor agonist: 3'-[(2Z)-[1-(3,4-dimethylphenyl)- 1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3- carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis- monoethanolamine salt, pharmaceutical compositions comprising the same, and methods of using such combinations in the treatment of thrombocytopenia.

BACKGROUND OF THE INVENTION

The macrolide:

3S-[3R^*[E(1 S^*,3S^*,4S^*)],4S\5R^*,8S\9E, 12R^*.14R^*.15S^*, 16R^*, 18S^*, 19S^*,26aR^*

-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1 -methylethenyl]-14,16-dimethoxy

-4,10, 12, 18-tetramethyl-8-(2-propenyl)-15, 19-epoxy-3H-pyrido[2, 1 -c] [1 ,4]

oxaazacyclotricosine-1 ,7,20,21 (4H,23H)tetrone, suitably as the monohydrate, is known

®

as tacrolimus, and is marketed under the trade name Prograf . Tacrolimus is

represented by the following Structure I:

and is suitably in the form of a monohydrate. Tacrolimus (also FK-506 or Fujimycin) is an immunosuppressive drug that is mainly used after allogeneic organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection. It reduces interleukin-2 (IL-2) production by T-cells. It is also used in a topical preparation in the treatment of severe atopic dermatitis (eczema), severe refractory uveitis after bone marrow transplants, and the skin condition vitiligo. It is a 23-membered macrolide lactone discovered in 1984 from the fermentation broth of a Japanese soil sample that contained the bacteria Streptomyces tsukubaensis.

The TPO receptor agonist: 3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl- 5-oxo-4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy-[1 ,1 '-biphenyl]-3-carboxylic acid is known by the generic name eltrombopag. The bis-monoethanolamine salt of eltrombopag is generically known as eltrombopag olamine. Eltrombopag olamine is marketed under the trade name Promacta® in the United States and Revolade® outside the United States. Eltrombopag olamine is represented by the following Structure II:

Eltrombopag is a compound which is disclosed and claimed, along with pharmaceutically acceptable salts, hydrates, solvates and esters thereof, as being useful as an agonist of the TPO receptor, particularly in enhancing platelet production and particularly in the treatment of thrombocytopenia, in International Application No. PCT/US01/16863, having an International filing date of May 24, 2001 ; International Publication Number WO 01/89457 and an International Publication date of November 29, 2001 . Eltrombopag is disclosed and claimed as being useful in the treatment of cancer and pre-cancerous syndromes in International Application No. PCT/US08/054046, having an International filing date of February 15, 2008; International Publication Number WO 08/101 141 and an International Publication date of August 21 , 2008.

It would be useful to provide a novel therapy which provides more effective and/or enhanced treatment of an individual suffering the effects of thrombocytopenia and allows for improved treatment of transplant rejection after organ transplant.

SUMMARY OF THE INVENTION

One embodiment of this invention provides a combination comprising: compound of the Structure

or a pharmaceutically acceptable salt or hydrate thereof; and (ii) a compound of the Structure:

or a pharmaceutically acceptable salt thereof.

One embodiment of this invention provides a method of treating thrombocytopenia and transplant rejection in a human in need thereof which comprises the in vivo administration of a therapeutically effective amount of a combination of tacrolimus, and eltrombopag olamine, to such human. One embodiment of this invention provides a method of treating thrombocytopenia and transplant rejection in a human in need thereof which comprises the in vivo administration of a therapeutically effective amount of a combination of tacrolimus, and eltrombopag olamine, to such human,

wherein the combination is administered within a specified period, and wherein the combination is administered for a duration of time. One embodiment of this invention provides a method of treating thrombocytopenia and transplant rejection in a human in need thereof which comprises the in vivo administration of a therapeutically effective amount of a combination of tacrolimus, and eltrombopag olamine, to such human,

wherein the compounds of the combination are administered sequentially.

DETAILED DESCRIPTION OF THE INVENTION

The present invention relates to combinations that exhibit the ability to enhance platelet production. Suitably, the method relates to methods of treating thrombocytopenia and transplant rejection by the co-administration of:

-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1 -methylethenyl]-14,16-dimethoxy

-4,10, 12, 18-tetramethyl-8-(2-propenyl)-15, 19-epoxy-3H-pyrido[2, 1 -c][1 ,4]

oxaazacyclotricosine-1 ,7,20,21 (4H,23H)tetrone, suitably as the monohydrate thereof, (hereinafter Compound A, suitably as the monohydrate thereof,

which compound is represented by Structure I:

and 3'-[(2Z)-[1-(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4- ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid, or a pharmaceutically acceptable salt, suitably the bis-monoethanolamine salt, thereof, (hereinafter Compound B or a pharmaceutically acceptable salt or solvate, suitably the bis-monoethanolamine salt, thereof,

which compound is represented by Structure II:

Compound A is a known immunosuppressive drug compound marketed under the generic name tacrolimus. Tacrolimus can generally be prepared as described in Japanese Kokai Patent Publication No. 61-148181/1986 and European Patent Publication No. 0323042. Suitably, Compound A is in the form of a monohydrate. Tacrolimus is marketed

®

under the trade name Prograf . Eltrombopag is a compound which is disclosed and claimed, along with pharmaceutically acceptable salts, hydrates, solvates and esters thereof, as being useful as an agonist of the TPO receptor, particularly in enhancing platelet production and particularly in the treatment of thrombocytopenia, in International Application No. PCT/US01/16863, having an International filing date of May 24, 2001 ; International Publication Number WO 01/89457 and an International Publication date of November 29, 2001 . Eltrombopag is disclosed and claimed as being useful in the treatment of cancer and pre-cancerous syndromes in International Application No. PCT/US08/054046, having an International filing date of February 15, 2008; International Publication Number WO 08/101 141 and an International Publication date of August 21 , 2008.

Suitably, Compound B is in the form of a bis-monoethanolamine salt. This salt form can be prepared by one of skill in the art from the description in International Application No. PCT/US03/16255 having an International filing date of May 21 , 2003; International Publication Number WO 03/098992 and an International Publication date of December 4, 2003.

The administration of a therapeutically effective amount of the combinations of the invention are advantageous over the individual component compounds in that the combinations will provide one or more of the following improved properties when compared to the individual administration of a therapeutically effective amount of a component compound: i) a greater platelet enhancing effect than the most active single agent, ii) a greater effect on transplant rejection than the most active single agent, iii) a dosing protocol that provides enhanced platelet enhancing activity with reduced side effect profile, iv) a dosing protocol that provides enhanced treatment for transplant rejection with reduced side effect profile, v) a reduction in the toxic effect profile, vi) an increase in the therapeutic window, or vii) an increase in the bioavailability of one or both of the component compounds. The compounds of the invention may contain one or more chiral atoms, or may otherwise be capable of existing as two enantiomers. Accordingly, the compounds of this invention include mixtures of enantiomers as well as purified enantiomers or enantiomerically enriched mixtures. Also, it is understood that all tautomers and mixtures of tautomers are included within the scope of Compound A, and pharmaceutically acceptable salts or hydrates thereof, and Compound B, and pharmaceutically acceptable salts thereof.

The compounds of the invention may form a solvate which is understood to be a complex of variable stoichiometry formed by a solute (in this invention, Compound A or a salt thereof and/or Compound B or a salt thereof) and a solvent. Such solvents for the purpose of the invention may not interfere with the biological activity of the solute. Examples of suitable solvents include, but are not limited to, water, methanol, dimethyl sulfoxide, ethanol and acetic acid. Suitably the solvent used is a pharmaceutically acceptable solvent. Suitably the solvent used is water.

The pharmaceutically acceptable salts of the compounds of the invention are readily prepared by those of skill in the art. By the term "thrombocytopenia" and derivatives thereof as used herein is to be broadly interpreted as any decrease in the number of blood platelets below what is considered normal or desired for a healthy individual. Thrombocytopenia is known to have many causative factors, including but not limited to, radiation therapy, chemotherapy, immune therapy, immune thrombocytopenic purpura (ITP, Bussel J. B., Seminars in Hematology, 2000, 37, Suppl 1 , 1-49), myelodysplasia syndrome (MDS), aplastic anemia, AML, CML, viral infections (including, but not limited to; HIV, hepatitis C, parvovirus) liver disease, myeloablation, bone marrow transplant, stem cell transplant, peripheral blood stem cell transplant, progenitor cell defect, polymorphisms in stem cells and progenitor cells, defects in Tpo, neutropenia (Sawai, N. J. Leukocyte Biol., 2000, 68, 137-43), dendritic cell mobilization (Kuter D. J. Seminars in Hematology, 2000, 37, Suppl 4, 41 -49), proliferation, activation or differentiation.

The combinations of this invention are advantageous in treating thrombocytopenia as the combination is expected to reduce any adverse immunological effect on platelet production. The combinations of this invention are advantageous in treating transplant rejection as the combination is expected to reduce the adverse side effects, suitably thrombocytopenia, caused by the administration of tacrolimus alone. Prophylactic use of the combinations of this invention is contemplated whenever a decrease in blood or blood platelets is anticipated. Prophylactic use of the combinations of this invention results in a build up of platelets or a commencement of platelet production prior to an anticipated loss of platelets, for example with the use of tacrolimus.

Also, contemplated herein is a method of treating thrombocytopenia using a combination of the invention where Compound A, or a pharmaceutically acceptable salt or hydrate thereof, and/or Compound B or a pharmaceutically acceptable salt thereof are administered as pro-drugs. Pharmaceutically acceptable pro-drugs of the compounds of the invention are readily prepared by those of skill in the art.

When referring to a dosing protocol, the term "day", "per day" and the like, refer to a time within one calendar day which begins at midnight and ends at the following midnight.

By the term "treating" and derivatives thereof as used herein, is meant therapeutic therapy. In reference to a particular condition, treating means: (1 ) to ameliorate or prevent the condition of one or more of the biological manifestations of the condition, (2) to interfere with (a) one or more points in the biological cascade that leads to or is responsible for the condition or (b) one or more of the biological manifestations of the condition, (3) to alleviate one or more of the symptoms, effects or side effects associated with the condition or treatment thereof, or (4) to slow the progression of the condition or one or more of the biological manifestations of the condition. Prophylactic therapy is also contemplated thereby. The skilled artisan will appreciate that "prevention" is not an absolute term. In medicine, "prevention" is understood to refer to the prophylactic administration of a drug to substantially diminish the likelihood or severity of a condition or biological manifestation thereof, or to delay the onset of such condition or biological manifestation thereof. Prophylactic therapy is appropriate, for example, when a subject is considered at high risk for developing thrombocytopenia, such as when a subject has a strong family history of thrombocytopenia or when open wounds and cuts can be expected such as when a subject is anticipating surgery.

As used herein, the term "effective amount" means that amount of a drug or pharmaceutical agent that will elicit the biological or medical response of a tissue, system, animal or human that is being sought, for instance, by a researcher or clinician. Furthermore, the term "therapeutically effective amount" means any amount which, as compared to a corresponding subject who has not received such amount, results in improved treatment, healing, prevention, or amelioration of a disease, disorder, or side effect, or a decrease in the rate of advancement of a disease or disorder. The term also includes within its scope amounts effective to enhance normal physiological function.

By the term "combination" and derivatives thereof, as used herein is meant either, simultaneous administration or any manner of separate sequential administration of a therapeutically effective amount of Compound A, or a pharmaceutically acceptable salt thereof, and Compound B or a pharmaceutically acceptable salt or solvate thereof. Preferably, if the administration is not simultaneous, the compounds are administered in a close time proximity to each other. Furthermore, it does not matter if the compounds are administered in the same dosage form, e.g. one compound may be administered topically and the other compound may be administered orally. Suitably, Compound A is administered by IV and Compound B is administered orally.

By the term "combination kit" as used herein is meant the pharmaceutical composition or compositions that are used to administer Compound A, or a pharmaceutically acceptable salt or hydrate thereof, and Compound B, or a pharmaceutically acceptable salt thereof, according to the invention. When both compounds are administered simultaneously, the combination kit can contain Compound A, or a pharmaceutically acceptable salt or hydrate thereof, and Compound B, or a pharmaceutically acceptable salt thereof, in a single pharmaceutical composition, such as a tablet, or in separate pharmaceutical compositions. When the compounds are not administered simultaneously, the combination kit will contain Compound A, or a pharmaceutically acceptable salt or hydrate thereof, and Compound B, or a pharmaceutically acceptable salt thereof, in separate pharmaceutical compositions. The combination kit can comprise Compound A, or a pharmaceutically acceptable salt or hydrate thereof, and Compound B, or a pharmaceutically acceptable salt thereof, in separate pharmaceutical compositions in a single package or in separate pharmaceutical compositions in separate packages.

In one aspect there is provided a combination kit comprising the components: Compound A, or a pharmaceutically acceptable salt or hydrate thereof, in association with a pharmaceutically acceptable carrier; and

Compound B, or a pharmaceutically acceptable salt thereof, in association with a pharmaceutically acceptable carrier.

In one embodiment of the invention the combination kit comprises the following components:

Compound A, or a pharmaceutically acceptable salt or hydrate thereof, in association with a pharmaceutically acceptable carrier; and

Compound B, or a pharmaceutically acceptable salt thereof, in association with a pharmaceutically acceptable carrier,

wherein the components are provided in a form which is suitable for sequential, separate and/or simultaneous administration.

In one embodiment the combination kit comprises:

a first container comprising Compound A, or a pharmaceutically acceptable salt or hydrate thereof, in association with a pharmaceutically acceptable carrier; and

a second container comprising Compound B, or a pharmaceutically acceptable salt thereof, in association with a pharmaceutically acceptable carrier, and a container means for containing said first and second containers.

The "combination kit" can also be provided by instruction, such as dosage and administration instructions. Such dosage and administration instructions can be of the kind that is provided to a doctor, for example by a drug product label, or they can be of the kind that is provided by a doctor, such as instructions to a patient.

2

As used herein the term "Compound A " means — Compound A, or a pharmaceutically acceptable salt or hydrate, suitably the monohydrate, thereof— .

2

As used herein the term "Compound B " means — Compound B, or a pharmaceutically acceptable salt, suitably the bis-monoethanolamine salt, thereof— . Suitably the combinations of this invention are administered within a "specified period".

By the term "specified period" and derivatives thereof, as used herein is meant the

2 2 interval of time between the administration of one of Compound A and Compound B

2 2

and the other of Compound A and Compound B . Unless otherwise defined, the specified period can include simultaneous administration. When both compounds of the invention are administered once a day the specified period refers to timing of the

2 2

administration of Compound A and Compound B during a single day. When one or both compounds of the invention are administered more than once a day, the specified period is calculated based on the first administration of each compound on a specific day. All administrations of a compound of the invention that are subsequent to the first during a specific day are not considered when calculating the specific period. Suitably, if the compounds are administered within a "specified period" and not administered simultaneously, they are both administered within about 24 hours of each other - in this case, the specified period will be about 24 hours; suitably they will both be administered within about 12 hours of each other - in this case, the specified period will be about 12 hours; suitably they will both be administered within about 1 1 hours of each other - in this case, the specified period will be about 1 1 hours; suitably they will both be administered within about 10 hours of each other - in this case, the specified period will be about 10 hours; suitably they will both be administered within about 9 hours of each other - in this case, the specified period will be about 9 hours; suitably they will both be administered within about 8 hours of each other - in this case, the specified period will be about 8 hours; suitably they will both be administered within about 7 hours of each other - in this case, the specified period will be about 7 hours; suitably they will both be administered within about 6 hours of each other - in this case, the specified period will be about 6 hours; suitably they will both be administered within about 5 hours of each other - in this case, the specified period will be about 5 hours; suitably they will both be administered within about 4 hours of each other - in this case, the specified period will be about 4 hours; suitably they will both be administered within about 3 hours of each other - in this case, the specified period will be about 3 hours; suitably they will be administered within about 2 hours of each other - in this case, the specified period will be about 2 hours; suitably they will both be administered within about 1 hour of each other - in this case, the specified period will be about 1 hour. As used herein, the administration of

2 2

Compound A and Compound B in less than about 45 minutes apart is considered simultaneous administration.

Suitably, when the combination of the invention is administered for a "specified period", the compounds will be co-administered for a "duration of time".

By the term "duration of time" and derivatives thereof, as used herein is meant that both compounds of the invention are administered within a "specified period" for an indicated number of consecutive days, optionally followed by a number of consecutive days where only one of the component compounds is administered. Unless otherwise defined, the "duration of time" and in all dosing protocols described herein, do not have to commence with the start of treatment and terminate with the end of treatment, it is only required that the number of consecutive days in which both compounds are administered and the optional number of consecutive days in which only one of the component compounds is administered, or the indicated dosing protocol, occur at some point during the course of treatment.

Regarding "specified period" administration:

Suitably, during the course of treatment, both compounds will be administered within a specified period for at least 1 day - in this case, the duration of time will be at least 1 day; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 2 consecutive days - in this case, the duration of time will be at least 2 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 3 consecutive days - in this case, the duration of time will be at least 3 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 5 consecutive days - in this case, the duration of time will be at least 5 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 7 consecutive days - in this case, the duration of time will be at least 7 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 14 consecutive days - in this case, the duration of time will be at least 14 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 30 consecutive days - in this case, the duration of time will be at least 30 days. When, during the course of treatment, both compounds are administered within a specified period for over 30 days, the treatment is considered chronic treatment and will continue until an altering event, such as a reassessment in cancer status or a change in the condition of the patient, warrants a modification to the protocol.

Further regarding "specified period" administration:

Suitably, during the course of treatment, both compounds will be administered within a specified period for at least 1 day, followed by the administration of Compound

2

A alone for at least 1 day - in this case, the duration of time will be at least 2 days; suitably, during the course of treatment, both compounds will be administered within a

2

specified period for at least 1 day, followed by administration of Compound A alone for at least 2 days - in this case, the duration of time will be at least 3 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at

2

least 1 day, followed by administration of Compound A alone for at least 3 days - in this case, the duration of time will be at least 4 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 1 day, followed

2

by administration of Compound A alone for at least 4 days - in this case, the duration of time will be at least 5 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 1 day, followed by administration of

2

Compound A alone for at least 5 days - in this case, the duration of time will be at least

6 days; suitably, during the course of treatment, both compounds will be administered

2 within a specified period for at least 1 day, followed by administration of Compound A alone for at least 6 days - in this case, the duration of time will be at least 7 days; suitably, during the course of treatment, both compounds will be administered within a

2

specified period for at least 1 day, followed by administration of Compound A alone for at least 7 days - in this case, the duration of time will be at least 8 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at

2

least 2 consecutive days, followed by administration of Compound A alone for at least 1 day - in this case, the duration of time will be at least 3 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 2

2

consecutive days, followed by administration of Compound A alone for at least 2 consecutive days - in this case, the duration of time will be at least 4 days; suitably, during the course of treatment, both compounds will be administered within a specified

2 period for at least 2 consecutive days, followed by administration of Compound A alone for at least 3 consecutive days - in this case, the duration of time will be at least 5 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 2 consecutive days, followed by administration of Compound

2

A alone for at least 4 consecutive days - in this case, the duration of time will be at least 6 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 2 consecutive days, followed by administration of

2

Compound A alone for at least 5 consecutive days - in this case, the duration of time will be at least 7 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 2 consecutive days, followed by

2

administration of Compound A alone for at least 6 consecutive days - in this case, the duration of time will be at least 8 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 2 consecutive days,

2

followed by administration of Compound A alone for at least 7 consecutive days - in this case, the duration of time will be at least 9 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 3 consecutive

2

days, followed by administration of Compound A alone for at least 1 day - in this case, the duration of time will be at least 4 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 3 consecutive days,

2

followed by administration of Compound A alone for at least 2 consecutive days - in this case, the duration of time will be at least 5 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 3 consecutive

2

days, followed by administration of Compound A alone for at least 3 consecutive days - in this case, the duration of time will be at least 6 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 3

2

consecutive days, followed by administration of Compound A alone for at least 4 consecutive days - in this case, the duration of time will be at least 7 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 3 consecutive days, followed by administration of Compound A alone for at least 5 consecutive days - in this case, the duration of time will be at least 8 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 3 consecutive days, followed by administration of Compound

2

A alone for at least 6 consecutive days - in this case, the duration of time will be at least 9 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 3 consecutive days, followed by administration of

2

Compound A alone for at least 7 consecutive days - in this case, the duration of time will be at least 10 days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 4 consecutive days, followed by

2

administration of Compound A alone for at least 1 day - in this case, the duration of time will be at least 5 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 4 consecutive days,

2

followed by administration of Compound A alone for at least 2 consecutive days - in this case, the duration of time will be at least 6 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 4

2

consecutive days, followed by administration of Compound A alone for at least 3 consecutive days - in this case, the duration of time will be at least 7 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 4 consecutive days, followed by administration of Compound

2

A alone for at least 4 consecutive days - in this case, the duration of time will be at least 8 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 4 consecutive days, followed by

2

administration of Compound A alone for at least 7 consecutive days - in this case, the duration of time will be at least 1 1 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 5

2

consecutive days, followed by administration of Compound A alone for at least 1 day - in this case, the duration of time will be at least 6 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at

2

least 5 consecutive days, followed by administration of Compound A alone for at least 2 consecutive days - in this case, the duration of time will be at least 7 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 5 consecutive days, followed by administration of Compound

2

A alone for at least 3 consecutive days - in this case, the duration of time will be at least

8 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 5 consecutive days, followed by

2

administration of Compound A alone for at least 4 consecutive days - in this case, the duration of time will be at least 9 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 5

2

consecutive days, followed by administration of Compound A alone for at least 5 consecutive days - in this case, the duration of time will be at least 10 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 7 consecutive days, followed by administration of Compound

2

A alone for at least 2 consecutive days - in this case, the duration of time will be at least

9 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 14 consecutive days, followed by

2

administration of Compound A alone for at least 7 consecutive days - in this case, the duration of time will be at least 21 consecutive days; suitably, during the course of treatment, both compounds will be administered within a specified period for at least 30

2

consecutive days, followed by administration of Compound A alone for at least 7 consecutive days - in this case, the duration of time will be at least 37 consecutive days. Suitably, during the course of treatment, both compounds will be administered within a specified period for from 1 to 3 consecutive days, followed by administration of

2

Compound A alone for from 3 to 7 consecutive days. Suitably, during the course of treatment, both compounds will be administered within a specified period for from 3 to 6

2

consecutive days, followed by administration of Compound A alone for from 1 to 4 consecutive days. Suitably, during the course of treatment, both compounds will be administered within a specified period for 5 consecutive days, followed by administration

2

of Compound A alone for 2 consecutive days. Suitably, during the course of treatment, both compounds will be administered within a specified period for 2 consecutive days,

2

followed by administration of Compound A alone for from 3 to 7 consecutive days. Suitably, during the course of treatment, both compounds will be administered within a specified period for from 1 to 3 days over a 7 day period, and during the other days of the 7 day period Compound A will be administered alone. Suitably, during the course of treatment, both compounds will be administered within a specified period for 2 days over

2 a 7 day period, and during the other days of the 7 day period Compound A will be administered alone.

Suitably, if the compounds are not administered during a "specified period", they are administered sequentially. By the term "sequential administration", and derivates

2 2 thereof, as used herein is meant that one of Compound A and Compound B is

2 administered for 1 or more consecutive days and the other of Compound A and

2

Compound B is subsequently administered for 1 or more consecutive days. Unless otherwise defined, the "sequential administration" and in all dosing protocols described herein, do not have to commence with the start of treatment and terminate with the end of

2 treatment, it is only required that the administration of one of Compound A and

2 2

Compound B followed by the administration of the other of Compound A and

2

Compound B , or the indicated dosing protocol, occur at some point during the course of treatment. Also, contemplated herein is a drug holiday utilized between the sequential

2 2 2 administration of one of Compound A and Compound B and the other of Compound A

2

and Compound B . As used herein, a drug holiday is a period of days after the

2 2

sequential administration of one of Compound A and Compound B and before the

2 2

administration of the other of Compound A and Compound B where neither Compound

2 2

A nor Compound B is administered. Suitably the drug holiday will be a period of days selected from: 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 1 1 days, 12 days, 13 days and 14 days.

Regarding sequential administration:

2 2

Suitably, one of Compound A and Compound B is administered for from 1 to 30 consecutive days, followed by an optional drug holiday, followed by administration of the

2 2

other of Compound A and Compound B for from 1 to 30 consecutive days. Suitably,

2 2

one of Compound A and Compound B is administered for from 1 to 21 consecutive days, followed by an optional drug holiday, followed by administration of the other of

2 2

Compound A and Compound B for from 1 to 21 consecutive days. Suitably, one of

2 2

Compound A and Compound B is administered for from 1 to 14 consecutive days, followed by a drug holiday of from 1 to 14 days, followed by administration of the other of

2 2

Compound A and Compound B for from 1 to 14 consecutive days. Suitably, one of

2 2

Compound A and Compound B is administered for from 2 to 7 consecutive days, followed by a drug holiday of from 2 to 10 days, followed by administration of the other of

2 2

Compound A and Compound B for from 2 to 7 consecutive days.

2

Suitably, Compound B will be administered first in the sequence, followed by an

2

optional drug holiday, followed by administration of Compound A . Suitably, Compound

2

B is administered for from 1 to 21 consecutive days, followed by an optional drug

2

holiday, followed by administration of Compound A for from 1 to 21 consecutive days.

2

Suitably, Compound B is administered for from 3 to 21 consecutive days, followed by a

2 drug holiday of from 1 to 14 days, followed by administration of Compound A for from 3

2

to 21 consecutive days. Suitably, Compound B is administered for from 3 to 21 consecutive days, followed by a drug holiday of from 3 to 14 days, followed by

2

administration of Compound A for from 3 to 21 consecutive days. Suitably, Compound

2

B is administered for 21 consecutive days, followed by an optional drug holiday, followed

2 2 by administration of Compound A for 14 consecutive days. Suitably, Compound B is administered for 14 consecutive days, followed by a drug holiday of from 1 to 14 days,

2

followed by administration of Compound A for 14 consecutive days. Suitably,

2

Compound B is administered for 7 consecutive days, followed by a drug holiday of from

2

3 to 10 days, followed by administration of Compound A for 7 consecutive days.

2

Suitably, Compound B is administered for 3 consecutive days, followed by a drug

2 holiday of from 3 to 14 days, followed by administration of Compound A for 7

2

consecutive days. Suitably, Compound B is administered for 3 consecutive days, followed by a drug holiday of from 3 to 10 days, followed by administration of Compound

2

A for 3 consecutive days.

2

Suitably, Compound A will be administered first in the sequence, followed by an

2

optional drug holiday, followed by administration of Compound B . Suitably, Compound

2

A is administered for from 1 to 21 consecutive days, followed by an optional drug

2

holiday, followed by administration of Compound B for from 1 to 21 consecutive days.

2

Suitably, Compound A is administered for from 3 to 21 consecutive days, followed by a

2 drug holiday of from 1 to 14 days, followed by administration of Compound B for from 3

2

to 21 consecutive days. Suitably, Compound A is administered for from 3 to 21 consecutive days, followed by a drug holiday of from 3 to 14 days, followed by

2

administration of Compound B for from 3 to 21 consecutive days. Suitably, Compound

2

A is administered for 21 consecutive days, followed by an optional drug holiday, followed

2 2 by administration of Compound B for 14 consecutive days. Suitably, Compound A is administered for 14 consecutive days, followed by a drug holiday of from 1 to 14 days,

2

followed by administration of Compound B for 14 consecutive days. Suitably,

2

Compound A is administered for 7 consecutive days, followed by a drug holiday of from

2

3 to 10 days, followed by administration of Compound B for 7 consecutive days.

2

Suitably, Compound A is administered for 3 consecutive days, followed by a drug

2 holiday of from 3 to 14 days, followed by administration of Compound B for 7

2

consecutive days. Suitably, Compound A is administered for 3 consecutive days, followed by a drug holiday of from 3 to 10 days, followed by administration of Compound

2 2

B for 3 consecutive days. Suitably, Compound A is administered for 7 consecutive

2 2 days, followed by administration of Compound B for 1 day. Suitably, Compound A is

2 administered for 6 consecutive days, followed by administration of Compound B for 1

2

day. Suitably, Compound B is administered for 1 day, followed by administration of

2 2

Compound A for 7 consecutive days. Suitably, Compound B is administered for 1 day,

2

followed by administration of Compound A for 6 consecutive days. It is understood that a "specified period" administration and a "sequential" administration can be followed by repeat dosing or can be followed by an alternate dosing protocol, and a drug holiday may precede the repeat dosing or alternate dosing protocol.

Suitably, the dosing protocol will be:

Compound A administered in:

a daily oral dose selected from: about 0.5mg, about 1 mg and about 5mg, by weight of the free or unsalted compound;

or

a daily oral dose of a combination independently selected from 2 or 3 of the following: about 0.5mg, about 1 mg and about 5mg, by weight of the free or unsalted compound;

or

a daily intravenous infusion selected from 0.01 mg/kg/day to about 0.05 mg/kg/day; and

Compound B administered in:

a daily dose selected from: about 12.5mg, about 25mg, about 50mg, about 75mg, and about 10Omg, by weight of the free or unsalted compound; and

the selected combination is suitably administered for a week, suitably for a month, suitably for a year, suitably for over one year.

2

Suitably, the amount of Compound A administered as part of the combination according to the present invention will be an amount selected from about 0.5mg to about

2

5mg. For example, the amount of Compound B administered as part of the combination according to the present invention can be 0.5mg, 1 mg, 1 .5mg, 2mg, 2.5mg, 3mg, 3.5mg, 4mg, 4.5mg, 5mg, 5.5mg, 6mg, 6.5mg, 7mg, 7.5mg, 8mg, 8.5mg, 9mg, 9.5mg, 10mg.

2

Suitably, the amount of Compound A administered as part of the combination according to the present invention will be an amount selected from about 12.5mg to about 100mg. For example, the amount of Compound B administered as part of the combination according to the present invention can be 12.5mg, 25mg, 50mg, 75mg, 100mg.

2 2 As used herein, all amounts specified for Compound A and Compound B are indicated as the administered amount of free or unsalted compound per dose.

The method of the present invention may also be employed with other therapeutic methods to increase platelet count, and for the treatment of thrombocytopenia.

While it is possible that, for use in therapy, therapeutically effective amounts of the combinations of the present invention may be administered as the raw chemical, it is preferable to present the combinations as a pharmaceutical composition or compositions.

Accordingly, the invention further provides pharmaceutical compositions, which include

2 2

Compound A and/or Compound B , and one or more pharmaceutically acceptable carriers. The combinations of the present invention are as described above. The carrier(s) must be acceptable in the sense of being compatible with the other ingredients of the formulation, capable of pharmaceutical formulation, and not deleterious to the recipient thereof. In accordance with another aspect of the invention there is also provided a process for the preparation of a pharmaceutical formulation including admixing

2 2

Compound A and/or Compound B with one or more pharmaceutically acceptable carriers. As indicated above, such elements of the pharmaceutical combination utilized may be presented in separate pharmaceutical compositions or formulated together in one pharmaceutical formulation.

Pharmaceutical formulations may be presented in unit dose forms containing a predetermined amount of active ingredient per unit dose. As is known to those skilled in the art, the amount of active ingredient per dose will depend on the condition being treated, the route of administration and the age, weight and condition of the patient. Preferred unit dosage formulations are those containing a daily dose or sub-dose, or an appropriate fraction thereof, of an active ingredient. Furthermore, such pharmaceutical formulations may be prepared by any of the methods well known in the pharmacy art. Compound A and Compound B may be administered by any appropriate route. Suitable routes include oral, rectal, nasal, topical (including buccal and sublingual), vaginal, and parenteral (including subcutaneous, intramuscular, intravenous, intradermal, intrathecal, and epidural). It will be appreciated that the preferred route may vary with, for example, the condition of the recipient of the combination and the cancer to be treated. It will also be appreciated that each of the agents administered may be administered by the

2 2

same or different routes and that Compound A and Compound B may be compounded

2 together in a pharmaceutical composition/formulation. Suitably, Compound A and

2

Compound B are administered in separate pharmaceutical compositions.

The compounds or combinations of the current invention are incorporated into convenient dosage forms such as capsules, tablets, or injectable preparations. Solid or liquid pharmaceutical carriers are employed. Solid carriers include, starch, lactose, calcium sulfate dihydrate, terra alba, sucrose, talc, gelatin, agar, pectin, acacia, magnesium stearate, and stearic acid. Liquid carriers include syrup, peanut oil, olive oil, saline, and water. Similarly, the carrier may include a prolonged release material, such as glyceryl monostearate or glyceryl distearate, alone or with a wax. The amount of solid carrier varies widely but, suitably, may be from about 25 mg to about 1 g per dosage unit. When a liquid carrier is used, the preparation will suitably be in the form of a syrup, elixir, emulsion, soft gelatin capsule, sterile injectable liquid such as an ampoule, or an aqueous or nonaqueous liquid suspension.

For instance, for oral administration in the form of a tablet or capsule, the active drug component can be combined with an oral, non-toxic pharmaceutically acceptable inert carrier such as ethanol, glycerol, water and the like. Powders are prepared by comminuting the compound to a suitable fine size and mixing with a similarly comminuted pharmaceutical carrier such as an edible carbohydrate, as, for example, starch or mannitol. Flavoring, preservative, dispersing and coloring agent can also be present. It should be understood that in addition to the ingredients mentioned above, the formulations may include other agents conventional in the art having regard to the type of formulation in question, for example those suitable for oral administration may include flavoring agents. As indicated, therapeutically effective amounts of the combinations of the

2 2

invention (Compound A in combination with Compound B ) are administered to a human. Typically, the therapeutically effective amount of the administered agents of the present invention will depend upon a number of factors including, for example, the age and weight of the subject, the precise condition requiring treatment, the severity of the condition, the nature of the formulation, and the route of administration. Ultimately, the therapeutically effective amount will be at the discretion of the attending physician. The combinations of the invention are tested for efficacy, advantageous and synergistic properties generally according to known procedures.

For example, 3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H- pyrazol-4-ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt thereof in an amount selected from 12.5mg, 25mg, 50mg, 75mg and 100 mg per day, based on the weight of free or unsalted compound, is administered with tacrolimus according to the known clinical studies performed on tacrolimus. Suitably, the present invention relates to a method for increasing platelet count, and/or treating thrombocytopenia and/or treating transplantation rejection.

This invention provides a combination comprising tacrolimus, and 3'-[(2Z)-[1-(3,4- dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy- [1 , 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt thereof.

This invention also provides for a combination comprising tacrolimus and 3'-[(2Z)- [1-(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4-ylidene]hydrazino]-2'- hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt thereof, for use in therapy.

This invention also provides for a combination comprising tacrolimus, and 3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4- ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt thereof, for use in treating thrombocytopenia and/or treating transplantation rejection. This invention also provides a pharmaceutical composition comprising a combination of tacrolimus, and 3'-[(2Z)-[1-(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5- oxo-4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt thereof. This invention also provides a combination kit comprising tacrolimus, and

3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4- ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt thereof. This invention also provides for the use of a combination comprising tacrolimus, and 3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4- ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt thereof, in the manufacture of a medicament.

This invention also provides for the use of a combination comprising tacrolimus, and 3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4- ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt thereof, in the manufacture of a medicament to treat thrombocytopenia and/or treating transplantation rejection.

This invention also provides a method of treating thrombocytopenia and/or treating transplantation rejection which comprises administering a combination of tacrolimus, and 3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4- ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid or a pharmaceutically acceptable salt thereof, suitably the bis-monoethanolamine salt thereof, to a subject in need thereof. The following examples are intended for illustration only and are not intended to limit the scope of the invention in any way.

Experimental Details

Example 1 - Capsule Composition

An oral dosage form for administering a combination of the present invention is produced by filing a standard two piece hard gelatin capsule with the ingredients in the proportions shown in Table I, below.

Table I

INGREDIENTS AMOUNTS

tacrolimus (of Compound A) 1 mg

3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo- 25mg

4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy-[1 , 1 -biphenyl]-

3-carboxylic acid bis-monoethanolamine (of Compound B)

Mannitol 250 mg

Talc 125 mg

Magnesium Stearate 8 mg

Example 2 - Capsule Composition

An oral dosage form for administering one of the compounds of the present invention is produced by filing a standard two piece hard gelatin capsule with the ingredients in the proportions shown in Table II, below.

Table II

INGREDIENTS AMOUNTS

tacrolimus (of Compound A) 5mg

Mannitol 150mg

Talc 16mg

Magnesium Stearate 4mg Example 3 - Capsule Composition

An oral dosage form for administering one of the compounds of the present invention is produced by filing a standard two piece hard gelatin capsule with the ingredients in the proportions shown in Table III, below.

Table III

INGREDIENTS AMOUNTS

3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo- 50mg

4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy-[1 , 1 -biphenyl]- 3-carboxylic acid bis-monoethanolamine (of Compound B)

Mannitol 150mg

Talc 12mg

Magnesium Stearate 8mg

Example 4 - Tablet Composition

The sucrose, microcrystalline cellulose and the compounds of the invented combination, as shown in Table IV below, are mixed and granulated in the proportions shown with a 10% gelatin solution. The wet granules are screened, dried, mixed with the starch, talc and stearic acid, then screened and compressed into a tablet.

Table IV

INGREDIENTS AMOUNTS

tacrolimus (of Compound A) 0.5mg

3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5- 75mg

oxo-4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy-[1 ,1 '- biphenyl]-3-carboxylic acid bis-monoethanolamine (of

Compound B)

Microcrystalline cellulose 300mg

sucrose 10mg

starch 40mg

talc 20mg

stearic acid 5mg Example 5 - Tablet Composition

The sucrose, microcrystalline cellulose and one of the compounds of the invented combination, as shown in Table V below, are mixed and granulated in the proportions shown with a 10% gelatin solution. The wet granules are screened, dried, mixed with the starch, talc and stearic acid, then screened and compressed into a tablet.

Table V

INGREDIENTS AMOUNTS

tacrolimus (Compound A) 5mg

Microcrystalline cellulose 200mg

sucrose 4mg

starch 2mg

talc 1 mg

stearic acid 0.5mg

Example 6 - Tablet Composition

The sucrose, microcrystalline cellulose and one of the compounds of the invented combination, as shown in Table VI below, are mixed and granulated in the proportions shown with a 10% gelatin solution. The wet granules are screened, dried, mixed with the starch, talc and stearic acid, then screened and compressed into a tablet.

Table VI

INGREDIENTS AMOUNTS

3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5- 10Omg

Compound B)

Microcrystalline cellulose 300mg

sucrose 40mg

starch 20mg

talc 10mg

stearic acid 5mg

Example 7 - Injectable Parenteral Composition

An injectable form for administering a compound of the presently invented combination is produced by stirring 1.5% by weight of tacrolimus (of Compound A) in 10% by volume propylene glycol in water.

While the preferred embodiments of the invention are illustrated by the above, it is to be understood that the invention is not limited to the precise instructions herein disclosed and that the right to all modifications coming within the scope of the following claims is reserved.

Claims

We claim:

1. A combination comprising

(i) a compound of Structure (I):

or a pharmaceutically acceptable salt or hydrate thereof; and

(ii) a compound of Structure (II):

or a pharmaceutically acceptable salt thereof.

2. A combination according to claim 1 where the compound of Structure (I) is in the form of a monohydrate and the compound of Structure (II) is in the form of a bis- monoethanolamine salt.

3. A combination kit comprising a combination according to claim 1 or claim 2 together with a pharmaceutically acceptable carrier or carriers.

4. A combination according to any one of claims 1 to 3 where the amount of the compound of Structure (I) is selected from: about 0.5mg, about 1 mg and about 5mg and that amount is administered from 1 to 3 times a day, and the amount of the compound of Structure (II) is an amount selected from: about 12.5mg, about 25mg, about 50mg, about 75mg, and about 100mg, and that amount is administered once per day.

5. Use of a combination according to any of claims 1 to 4 in the manufacture of a medicament or medicaments for the treatment of thrombocytopenia and/or treating transplantation rejection.

6. A method of treating thrombocytopenia and/or treating transplantation rejection in a human in need thereof which comprises the in vivo administration of a therapeutically effective amount of a combination of

3S-[3R^*[E(1 S^*,3S^*,4S^*)],4S\5R^*,8S\9E, 12R^*.14R^*.15S^*, 16R^*.18S^*, 19S^*,26aR^* -5,6,8, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19,24,25,26,26a-hexadecahydro-5, 19-dihydroxy

-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1 -methylethenyl]-14,16-dimethoxy

-4,10, 12, 18-tetramethyl-8-(2-propenyl)-15,19-epoxy-3H-pyrido[2, 1 -c][1 ,4]

oxaazacyclotricosine-1 ,7,20,21 (4H,23H)tetrone, or a hydrate thereof, and 3'-[(2Z)-[1-(3,4- dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy- [1 , 1 '-biphenyl]-3-carboxylic acid, or a pharmaceutically acceptable salt thereof, to such human,

wherein the combination is administered within a specified period, and wherein the combination is administered for a duration of time.

7. A method of treating thrombocytopenia and/or treating transplantation rejection in a human in need thereof which comprises the in vivo administration of a combination of 3S- [3R^*[E(1 S\3S\4S^*)],4S^*,5R\8S^*,9E, 12R^*, 14R^*.15S^*, 16R^*, 18S^*, 19S^*,26aR^*

-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1 -methylethenyl]-14,16-dimethoxy

-4,10, 12, 18-tetramethyl-8-(2-propenyl)-15, 19-epoxy-3H-pyrido[2, 1 -c][1 ,4]

oxaazacyclotricosine-1 ,7,20,21 (4H,23H)tetrone monohydrate, and 3'-[(2Z)-[1-(3,4- dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4-ylidene]hydrazino]-2'-hydroxy- [1 , 1 '-biphenyl]-3-carboxylic acid bis-monoethanolamine;

wherein the administration protocol is:

3S-[3R^*[E(1 S^*,3S^*,4S^*)],4S\5R^*,8S\9E, 12R^*.14R^*.15S^*, 16R^*, 18S^*, 19S^*,26aR^* -5,6,8, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19,24,25,26,26a-hexadecahydro-5, 19-dihydroxy

-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1 -methylethenyl]-14,16-dimethoxy

-4,10, 12, 18-tetramethyl-8-(2-propenyl)-15,19-epoxy-3H-pyrido[2, 1 -c][1 ,4]

oxaazacyclotricosine-1 ,7,20,21 (4H,23H)tetrone monohydrate administered in:

and

3'-[(2Z)-[1 -(3,4-dimethylphenyl)-1 ,5-dihydro-3-methyl-5-oxo-4H-pyrazol-4- ylidene]hydrazino]-2'-hydroxy-[1 , 1 '-biphenyl]-3-carboxylic acid bis-monoethanolamine administered in:

a daily dose selected from: about 12.5mg, about 25mg, about 50mg, about 75mg, and about 10Omg, by weight of the free or unsalted compound.

8. A method according to claim 7 wherein said thrombocytopenia is due to myelosuppression caused by chemotherapy or radiation therapy.

9. A method according to claim 7 wherein said thrombocytopenia is due to an organ transplant.

10. A method according to claim 7 wherein said thrombocytopenia is due to bone marrow, stem cell, or liver transplant.

1 1 . A method according to claim 7 wherein said thrombocytopenia is due to idiopathic thrombocytopenia purpura (ITP).

12. A method according to claim 7 wherein said thrombocytopenia is due to myelodysplastic syndromes (MDS), aplastic anemia or leukemia.

13. A method according to claim 7 wherein said thrombocytopenia is due to viral, fungal, microbial or parasitic infection.

14. A method according to claim 7 wherein said thrombocytopenia is due to liver dysfunction.

15. A method according to claim 7 wherein said thrombocytopenia is due to surgical procedures.

16. A method according to claim 7 wherein said thrombocytopenia is due to treatment with antiviral or antibiotic agents.

17. A method according to claim 7 wherein said transplantation rejection is duegan transplant.