WO2020185805A1

WO2020185805A1 - Immune modulation by brequinar

Info

Publication number: WO2020185805A1
Application number: PCT/US2020/021939
Authority: WO
Inventors: David Brian SYKES; Vikram S. Kumar; Andrew D. LEVIN; David Scadden; Burt Alan ADELMAN
Original assignee: Clear Creek Bio, Inc.
Priority date: 2019-03-14
Filing date: 2020-03-11
Publication date: 2020-09-17

Abstract

The invention provides technologies for the improvement of immuno-oncology therapy. The present disclosure encompasses the recognition that brequinar may be useful in improving the safety and efficacy of immuno-oncology (IO) treatments. The goal of IO is to use patient's own immune system to eliminate cancerous cells. Examples of IO treatments may include hematopoietic stem cell transplantation (HSCT), cancer vaccines (alone or in combination with adoptive T cell immunotherapy), monoclonal antibodies (mAbs), and chimeric antigen receptor (CAR) T cell therapy.

Description

IMMUNE MODULATION BY BREQUINAR

Cross-Reference to Related Application

This application claims the benefit of, and priority to, U.S. Provisional Patent Application No. 62/818,186, filed March 14, 2019, the contents of which are incorporated by reference.

Background

[1] Immuno-oncology (10) treatments hold great promise for the treatment of cancers and autoimmune disorders. While powerful, many 10 treatments (particularly “chimeric antigen receptor T cell” (CAR T cell) therapies), can be associated with serious and severe side effects, e.g., cytokine release syndrome (CRS), which can cause fever, nausea, chills, hypotension, tachycardia, asthenia, headache, rash, scratchy throat, dyspnea, cerebral edema, organ failure, and even death.

Summary

[2] The present disclosure encompasses the recognition that brequinar may be useful in improving the safety and efficacy of immuno-oncology (IO) treatments. The goal of IO is to use a patient’s own immune system to eliminate cancerous cells. Examples of IO treatments may include hematopoietic stem cell transplantation (HSCT), cancer vaccines (alone or in combination with adoptive T cell immunotherapy), monoclonal antibodies (mAbs), and chimeric antigen receptor (CAR) T cell therapy. While IO treatments are powerful and hold great promise, they can also be associated with serious and severe side effects. There remains a need in the art for treatments to improve the safety profile of IO treatments.

Detailed Description

[3] All references cited within this disclosure are herein incorporated by reference in their entireties. Autoimmune Toxicity

[4] Despite their different mechanisms of action, there are two broad categories of common risk associated with 10 therapies: autoimmune toxicity and cytokine-associated toxicity. Autoimmune toxicity may result from an antigen-specific attack on host tissues when the targeted tumor associated antigen is expressed on nonmalignant tissue. It may result due to increased immune activation due to 10 therapy. It may preferentially affect patients with pre-existing autoimmune disease such as rheumatoid arthritis, inflammatory bowel disease, and psoriasis.

Cytokine Release Syndrome

[5] Cytokine associated toxicity, also referred to as cytokine release syndrome (CRS) or cytokine storm, is a non-antigen specific toxicity that occurs as a result of high- level immune activation. The degree of immune activation necessary to obtain clinical benefit using IO typically exceeds the level of immune activation that occurs during natural immune activation. As IO therapies have increased in potency and efficacy, CRS is increasingly recognized as a problem requiring a solution.

[6] CRS is clinically observed in cases where large numbers of lymphocytes (B cells, T cells, and/or natural killer cells) and/or myeloid cells (macrophages, dendritic cells, and monocytes) become activated and release inflammatory cytokines including IL-Ib, TNFa, IRNb, IFNy, IL-6, and IL-8. CRS is caused by a hyperactivated T cell response which is not tissue specific and thus causes reactivity with normal issue. This results in the production of high levels of CD4 T-helper cell cytokines or increased migration of cytolytic CD8 T cells within normal tissues. Weber, J. S., et ak,“Toxicities of Immunotherapy for the Practitioner,” Journal of Clinical Oncology, 33, no. 18 (June 2015) 2092-2099. The onset of symptoms may occur within a period of minutes to hours after administration of an IO therapy. Timing of symptom onset and CRS severity may depend on the inducing agent and the magnitude of the resulting immune cell activation. CRS can lead to serious organ damage and failure; such injury includes pulmonary infiltrates, lung injury, acute respiratory distress syndrome, cardiac dysfunction, cardiovascular shock, neurologic toxicity, disseminated intravascular coagulation (DIC), hepatic failure, or renal failure.

[7] CRS has been reported following the administration of IO therapies including HSCT, cancer vaccines (either alone or in combination with adoptive T cell therapy), mAbs, and CAR-T cells. CRS is a potentially life-threatening toxicity, with some patients requiring extensive intervention and life support. Patients have experienced neurological damage and/or death. Diagnosis and management of CRS in response to immune cell-based therapies is routinely based on clinical parameters and symptoms. Lee et al. has described a revised CRS grading system, shown below in Table 1. Lee, D. et al. (2014) Blood 124(2): 188-195.

Table 1: CRS Revised Grading System (Lee, D. et al. (2014) Blood 124(2): 188-195 at p. 191).

Grades 2-4 refer to CTCAE v4.0 grading.

*High-dose vasopressor doses shown in Table 3.

[8] Standard treatment involves vigilant supportive care and treatment with immunosuppressive drugs (e.g., anti-cytokine antibodies such as tocilizumab and corticosteroids). Management of CRS must be balanced with ensuring the efficacy of IO treatments. While early and/or aggressive immunosuppression may mitigate CRS, it may also limit the efficacy of the therapy. There have been reports that CRS may actually be necessary for effective treatment. The goal of CRS management is not to completely suppress it, but to prevent life-threatening toxicity while maximizing any antitumor effects. Lee, D. et al. (2014) Blood 124(2): 188-195.

Immuno-Oncology Therapy

[9] The present disclosure relates particularly to methods of improving the safety of immuno-oncology (10) treatments while maintaining efficacy. Cancer or autoimmune disease may be viewed as the result of a dysfunction of the normal immune system. The goal of IO is to utilize a patient’s own immune system to effect treatment of a disorder. IO treatments may include hematopoietic stem cell transplantation (HSCT), cancer vaccines, monoclonal antibodies (mAbs), and adoptive T cell immunotherapy.

1. CAR-T Cell Therapy

[10] Adoptive T cell immunotherapy may be performed with either natural T cells or with engineered T cells. Engineered T cells can include T cells which have been engineered to express chimeric antigen receptors (CARs) on their surface (CAR-T cells).

[11] Autologous adoptive cell transfer involves the collection, modification, and return of a patient's immune cells, offering a promising immunotherapeutic approach for the treatment of different types of cancers. Typically, leukocytes are isolated, usually by well- established density barrier centrifugation, and T lymphocytes are expanded ex vivo using cell culture methods, often relying on the immunomodulatory action of interleukin- 2. Once expanded, the cells are administered intravenously to the patent in an activated state. Such cells are referred to as effector T cells. In addition, a combination of anti-CD3 and anti- CD28 antibodies may be used as a surrogate for antigen presentation with appropriate co stimulation cues to promote the proliferation of T cells in culture.

[12] For T cells, engagement of the CD4⁺ and CD8⁺ T cell receptor (TCR) alone is not sufficient to induce persistent activation of resting naive or memory T cells. Fully functional, productive T cell activation requires a second co- stimulatory signal from a competent antigen-presenting cell (APC).

[13] Co-stimulation is achieved naturally by the interaction of CD28, a co stimulatory cell surface receptor on T cells, with a counter-receptor on the surface of the APC, e.g., CD80 and/or CD86. An APC may also be used for the antigen-dependent activation of T cells. To induce functional activation rather than toleragenic T cells, APCs must also express on their surface a co-stimulatory molecule. Such APCs are capable of stimulating T cell proliferation, inducing cytokine production, and acting as targets for cytolytic T lymphocytes (CTL) upon direct interaction with the T cell.

[14] Recently, T cells have been genetically engineered to produce artificial T cell receptors on their surface called chimeric antigen receptors (CARs). CARs allow T cells to recognize a specific, pre-selected protein, or antigen, found on targeted tumor cells. CAR-T cells can be cultured and expanded in the laboratory, then re- infused to patients in a similar manner to that described above for adoptive transfer of native T cells. The CAR directs the CAR-TT cell to a target cell expressing an antigen to which the CAR is specific. The CAR- TT cell binds the target and through operation of a stimulatory domain activates the CAR- TT cell. In some embodiments, the stimulatory domain is selected from CD28, 0X40, CD27, CD2, CD5, ICAM-1, LFA-1 (CDlla/CD18), 4-1BB, or a combination thereof.

[15] CARs may be specific for any tumor antigen. In some embodiments, a CAR comprises an extracellular binding domain specific for a tumor antigen. In some embodiments, a tumor antigen is selected from TSHR, CD19, CD123, CD22, CD30,

CD171, CS-1, CLL-1, CD33, EGFRvIII , GD2, GD3, BCMA, Tn Ag, PSMA, ROR1, FLT3, FAP, TAG72, CD38, CD44v6, CEA, EPCAM, B7H3, KIT, IL-13Ra2, Mesothelin, IL-1 IRa, PSCA, PRSS21, VEGFR2, Lewis Y, CD24, PDGFR-beta, SSEA-4, CD20, Folate receptor alpha, ERBB2 (Her2/neu), MUC1, EGFR, NCAM, Prostase, PAP, ELF2M, Ephrin B2, IGF- I receptor, CAIX, LMP2, gplOO, bcr-abl, tyrosinase, EphA2, Fucosyl GM1, sLe, GM3, TGS5, HMWMAA, o-acetyl-GD2, Folate receptor beta, TEM1/CD248, TEM7R, CLDN6, GPRC5D, CXORF61, CD97, CD179a, ALK, Polysialic acid, PLAC1, GloboH, NY-BR-1, UPK2, HAVCR1, ADRB3, PANX3, GPR20, LY6K, OR51E2, TARP, WT1, NY-ESO-1, LAGE-la, MAGE-A1, legumain, HPV E6,E7, MAGE Al, ETV6-AML, sperm protein 17, XAGE1, Tie 2, MAD-CT-1, MAD-CT-2, Fos-related antigen 1, p53, p53 mutant, prostein, survivin and telomerase, PCTA-l/Galectin 8, MelanA/MARTl, Ras mutant, hTERT, sarcoma translocation breakpoints, ML-IAP, ERG (TMPRSS2 ETS fusion gene), NA17, PAX3, Androgen receptor, Cyclin Bl, MYCN, RhoC, TRP-2, CYP1B1, BORIS, SART3, PAX5, OY-TES1, LCK, AKAP-4, SSX2, RAGE-1, human telomerase reverse transcriptase, RU1, RU2, intestinal carboxyl esterase, mut hsp70-2, CD79a, CD79b, CD72, LAIR1,

FCAR, LILRA2, CD300LF, CLEC12A, BST2, EMR2, LY75, GPC3, FCRL5, and IGLL1.

[16] In some embodiments, a CAR comprises an extracellular binding domain specific for a tumor targeting antibody. In some embodiments, an extracellular binding domain specific for a tumor targeting antibody binds an Fc portion of a tumor targeting antibody. In some embodiments, an extracellular binding domain specific for a tumor targeting antibody comprises an Fc receptor or an Fc binding portion thereof. In some embodiments, an Fc receptor is an Fc-gamma receptor, an Fc-alpha receptor, or an Fc- epsilon receptor. In some embodiments, an extracellular binding domain can be an extracellular ligand-binding domain of CD 16 (e.g., CD16A or CD16B), CD32 (e.g.,

CD32A, or CD32B), or CD64 (e.g., CD64A, CD64B, or CD64C).

[17] In some embodiments, a CAR comprises a transmembrane domain. In some embodiments, a transmembrane domain is selected from CD8a, CD8p, 4-1BB, CD28, CD34, CD4, FcsRIy, CD16 (e.g., CD16A or CD16B), 0X40, CD3 , CD3s, CD3y, CD35, TCRa, CD32 (e.g., CD32A or CD32B), CD64 (e.g., CD64A, CD64B, or CD64C),

VEGFR2, FAS, and FGFR2B, or a combination thereof. In some embodiments, the transmembrane domain is not CD 8 a. In some embodiments, a transmembrane domain is a non-naturally occurring hydrophobic protein segment.

[18] In some embodiments, a CAR comprises a co-stimulatory domain for T cell activation. In some embodiments, a co-stimulatory domain is selected from CD28, 0X40, CD27, CD2, CD5, ICAM-1, LFA-1 (CDlla/CD18), 4-1BB, GITR, HVEM, TIM1, LFA1, or CD2, a functional fragment thereof, or a combination thereof. In some embodiments, a CAR comprises two or more co-stimulatory domains. In some embodiments, the two or more co-stimulatory domains are selected from CD28, 0X40, CD27, CD2, CD5, ICAM-1, LFA-1 (CD 11 a/CD 18), 4- IBB, GITR, HVEM, TIM1, LFA1, or CD2.

[19] CRS is a common and potentially lethal complication of CAR-T cell therapy. It is a non-antigen specific toxicity that can occur as a result of the high-levels of CAR-T cell expansion and immune activation typically required to mediate clinical benefit using modern immunotherapies such as CAR-T cell transfer. Timing of symptom onset and CRS severity depends on the inducing agent and the magnitude of immune cell activation.

Symptom onset typically occurs days to occasionally weeks after T cell infusion, coinciding with maximal in vivo T cell expansion.

[20] The incidence and severity of CRS following CAR-T cell therapy for cancer has recently been reported to be greater in patients having large tumor burdens. Without wishing to be bound by any theory, it is believed that this is due to the expression of production of pro-inflammatory cytokines such as TNF-a by the adoptively transferred expanding and activated CAR-T cell populations. CRS following CAR-T cell therapy has been consistently associated with elevated IRNg, IL-6, and TNF-a levels, and increases in IL-2, granulocyte macrophage-colony- stimulating factor (GM-CSF), IL-10, IL-8, IL-5, and fracktalkine have also been reported.

2. Cancer Vaccines

[21] In some embodiments an 10 therapy is a cancer vaccine. A cancer vaccine is an immunogenic composition which stimulates a patient’s immune system to produce anti tumor antibodies, thereby enabling the immune system to target and destroy cancerous cells. In some embodiments, a cancer vaccine is a peptide vaccine. In some embodiments, a cancer vaccine is a conjugate vaccine.

[22] In some embodiments, a cancer vaccine is used in combination with adoptive T cell therapy. In some embodiments, a cancer vaccine is administered to a patient, after which tumor specific T cells are obtained from the patient, isolated, expanded ex vivo, and then administered to the patient. In some embodiments, the ex vivo expansion of tumor specific T cells provides for a method of obtaining a greater number of T cells which may attack and kill cancerous cells than what could be obtained by vaccination alone. In some embodiments, adoptive T cell therapy comprises culturing tumor infiltrating lymphocytes.

In some embodiments, one particular T cell or clone is isolated and expanded ex vivo prior to administration to a patient. In some embodiments, a T cell is obtained from a patient who has received a cancer vaccine.

[23] Administration of cancer vaccines, either alone or in combination with adoptive T cell transfer has been reported to result in CRS.

3. HSCT

[24] HSCT is“hematopoietic stem cell transplantation” to reestablish

hematopoietic function in a patient with defective bone marrow or immune system. In some embodiments, the stem cells are autologous. In some embodiments, the stem cells are allogeneic. In some embodiments the transplant is performed by intravenous infusion.

[25] In some embodiments, autologous HSCT may be used to treat multiple myeloma, non-Hodgkin lymphoma, Hodgkin disease, acute myeloid leukemia,

neuroblastoma, germ cell tumors, autoimmune disorders (e.g., systemic lupus erythematosus [SLE], systemic sclerosis), or amyloidosis. [26] In some embodiments, allogeneic HSCT may be used to treat acute myeloid leukemia, acute lymphoblastic leukemia, chronic myeloid leukemia, chronic lymphocytic leukemia, myeloproliferative disorders, myelodysplastic syndromes, multiple myeloma, non-Hodgkin lymphoma, Hodgkin disease, aplastic anemia, pure red-cell aplasia, paroxysmal nocturnal hemoglobinuria, Fanconi anemia, thalassemia major, sickle cell anemia, severe combined immunodeficiency (SCID), Wiskott-Aldrich syndrome, hemophagocytic lymphohistiocytosis, inborn errors of metabolism, Epidermolysis Bullosa, severe congenital neutropenia, Shwachman-Diamond syndrome, Diamond-Blackfan anemia, or leukocyte adhesion deficiency.

[27] In some embodiments, stem cells are obtained from a donor for

administration to a patient. In some embodiments, the donor is an identical twin of the patient. In some embodiments, the donor is a matched donor related to the patient. In some embodiments, the donor is a matched donor unrelated to the patient. In some embodiments, the donor is a mismatched donor related to the patient. In some embodiments, the donor is haploidentical to the patient.

[28] In some embodiments stem cells are obtained from bone marrow, peripheral blood, or umbilical cord blood.

[29] HSCT may result in graft vs. host disease (GvHD), which remains a major cause of morbidity and mortality in patients undergoing HSCT. Even though there have been advances in prevention and post-transplant immunosuppressive strategies, it is estimated that 20-50% of all HSCT patients will experience at least moderate GvHD.

Inflammatory cytokine release, e.g., CRS, is likely the primary mediator of acute GvHD, and activation of T cells is one step in this complex process. Ball, L. M. & Egeler, R. M., “Acute GvHD: pathogenesis and classification,” Bone Marrow Transplantation (2008) 41, S58-S64. Bouchlaka, M. N.,“Immunotherapy following hematopoietic stem cell transplantation: potential for synergistic effects,” Immunotherapy. 2010 May; 2(3): 399- 418.

4. mAbs

[30] Monoclonal antibodies are useful in the treatment of various cancers. mAh cancer treatments utilize natural immune system functions to attack cancerous cells.

Administration of mAbs specific for tumor antigens can be useful in targeting the tumor cells for destruction by the immune system. In some cases mAbs can trigger lysis of cancer cells, block cancer cell growth/replication, prevent angiogenesis, act as checkpoint inhibitors, and in some cases act to bind a tumor antigen while also activating specific immune cells. In some embodiments, a monoclonal antibody is monospecific. In some embodiments, a monoclonal antibody is bispecific. In some embodiments, a monoclonal antibody is a checkpoint inhibitor. In some embodiments, a mAh may be used in combination with CAR-T therapy.

[31] When activated by therapeutic monoclonal antibodies, T cell surface receptors can cause CRS. In some embodiments, antibodies which may induce CRS include anti-CD3 antibodies, anti-CD20 antibodies, anti-CD28 antibodies, anti-CTLA-4 antibodies, anti-PD-1 antibodies, and anti-PD-Ll antibodies. In some embodiments, antibodies which may induce CRS include alemtuzumab, muromonab-CD3, rituximab, tosituzumab, CP- 870,893, LO-CD2a/BTI-322, TGN1412, pembrolizumab, nivolumab, and ipilimumab.

Brequinar

[32] Despite the various modalities by which 10 therapies act and by which such therapies may induce CRS, the present disclosure encompasses the unexpected insight that brequinar may prove useful and effective to modulate T cell activity in subjects receiving 10 therapy, and thereby to mitigate or prevent certain undesirable side effects of that 10 therapy. The present disclosure teaches that brequinar can be administered in doses, and according to a regimen, relative to administration of 10 therapy, so that one or more undesirable effects of the 10 therapy are reduced (e.g., that has been observed when such 10 therapy, or comparable 10 therapy, is administered absent brequinar).

[33] Brequinar is a quinoline carboxylic acid described in U.S. Pat. No. 4,680,299, issued Jul. 14, 1987. The term“brequinar” as used herein refers to brequinar sodium, which is the compound 2-(2’-fluoro-l,r-biphenyl-4-yl )-6-fluoro-3-methyl-4-quinoline-carboxylic acid, sodium salt, or other suitable salts or free acids thereof, and has the formula:

Brequinar Sodium

[34] Brequinar is a potent inhibitor of dihydroorotate dehydrogenase (DHODH), the fourth enzyme in the de novo pyrimidine biosynthetic pathway. Brequinar is known to have cytotoxic attributes. A structure activity relationship for the inhibition of DHODH by quinoline carboxylic acids such as brequinar has been developed, S-F. Chen et al., Biochem. Pharmacol. 40:709-714 (1990). The effect of the DHO-DH inhibition by quinoline carboxylic acids such as brequinar is to deplete the plasma uridine concentrations in animals and patients, G. J. Peters et al., Cancer Res. 50:4644-4649 (1990). While brequinar was previously thought to have potential uses in treatment of cancer, phase I and II clinical trials showed disappointing efficacy in the treatment of solid tumors. Maroun, J., et al.

“Multicenter phase II study of brequinar sodium in patients with advanced lung cancer.” Cancer Chemother Pharmacol (1993) 32:64-66.; Bork, E., et al.,“A Phase I Clinical and Pharmacokinetic Study of Brequinar Sodium, DUP 785 (NW 368390), Using a Weekly and a Biweekly Schedule,” Eur J Cancer Clin Oncol, Vol. 25, No. 10, pp. 1403-1411, 1989; Arteaga, C. L., et al.,“Phase I Clinical and Pharmacokinetic Trial of Brequinar Sodium (DUP 785; NSC 368390),” Cancer Research, 49, 4648-53 (1989).

[35] Dosing regimens according to which brequinar has been administered to cancer patients include, for example:

(1) a single daily intravenous bolus over a 5-day period repeated every 28 days, at doses ranging from 36 to 300 mg/m²/day (See Arteaga et al Cancer Res 49:4648, 1989)

(2) short-term (e.g., 1 hour) intravenous infusion, repeated every 3 weeks, at doses including 1200 mg/m², 1500 mg/m², 1800 mg/m², and 2250 mg/m². (See

Schwartsmann et al., Cancer Chemother Pharmacol 25:345, 1990). Recommended doses have been 1200 mg/m² for so-called“poor risk” patients (based on a reported maximum tolerated dose of 1500 mg/m²), and 1800 mg/m² for“good risk”) patients (based on a reported maximum tolerated dose 2250 mg/m²) for this population.

(3) intraperitoneal injection of 50 mg/kg daily for 5 days (to patients with head and neck or lung cancers; see Boven, et al. Cancer Res 52: 5940, 1992)

A median weekly dose of 1200 mg/m² i.v. has been reported not to have activity as a therapeutic treatment for advanced melanoma. (See, Natale, Ann Oncol 3:659, 1992). Each of these dosing regimens may be considered a“reference” dosing regimen with respect to the present invention. In some embodiments, brequinar may be administered in combination with 10 therapy as described herein according to such a reference regimen. In many embodiments, however, brequinar is administered in accordance with the present invention in accordance with a regimen that provides lower peak exposure with more sustained effective inhibition of the enzyme (e.g., via reduced dose amount, number of doses, frequency of doses, route of administration, formulation, etc.) of the subject to brequinar than is achieved by such reference dosing regimens.

[36] More recently, DHODH inhibitors have been found to have the potential to overcome the differentiation blockade in acute myeloid leukemia, thereby reducing leukemic cell burden, decreasing levels of leukemia-initiating cells, and improving survival. Sykes, D. B., et ah,“Inhibition of Dihydroorotate Dehydrogenase Overcomes

Differentiation Blockade in Acute Myeloid Leukemia,” Cell. 167, 171-186, September 22, 2016.

[37] The present disclosure encompasses the surprising finding that brequinar, in combination with IO treatment, may be useful in treating or preventing T cell related adverse effects, such as CRS, autoimmune toxicity, uncontrolled activation of T cells, and/or uncontrolled proliferation of T cells. Without wishing to be bound by any theory, the present disclosure proposes that brequinar may have particular efficacy in the context of rapidly dividing cells and/or specifically with respect to T cells (e.g., rapidly dividing T cells). In some embodiments brequinar may operate to modulate the rate of T cell activation and/or proliferation.

[38] The present disclosure further encompasses the unexpected result that brequinar may increase the efficacy of IO treatment by enhancing antigen presentation. Without wishing to limit this finding, a particular exemplification is the differentiation of myeloid precursor cells into APCs (e.g., acute monocytic leukemia, or AML-M5, has a preponderance of monocytic lineage blasts that can be differentiated into APC dendritic cells by the action of brequinar). This enhanced antigen presentation, increases the efficacy of IO, by enhancing the immune response.

Methods of Treatment [39] In some embodiments, a patient has a disease associated with expression of a tumor antigen, e.g., a proliferative disease, a precancerous condition, a cancer, and a non cancer related indication associated with expression of the tumor antigen.

[40] In some embodiments, a subject has a cancer involving one or more solid tumors. In some embodiments, a subject has a hematologic cancer.

[41] In some embodiments, a hematologic cancer is selected from the group consisting of chronic lymphocytic leukemia (CLL), acute leukemias, acute lymphoid leukemia (ALL), B-cell acute lymphoid leukemia (B-ALL), T cell acute lymphoid leukemia (T-ALL), chronic myelogenous leukemia (CML), B cell prolymphocytic leukemia, blastic plasmacytoid dendritic cell neoplasm, Burkitt’s lymphoma, diffuse large B cell lymphoma, follicular lymphoma, hairy cell leukemia, small cell- or a large cell-follicular lymphoma, malignant lymphoproliferative conditions, MALT lymphoma, mantle cell lymphoma, marginal zone lymphoma, multiple myeloma, myelodysplasia and myelodysplastic syndrome, non-Hodgkin's lymphoma, Hodgkin's lymphoma, plasmablastic lymphoma, plasmacytoid dendritic cell neoplasm, Waldenstrom macroglobulinemia, preleukemia, and combinations thereof.

[42] In some embodiments, a cancer is selected from the group consisting of colon cancer, rectal cancer, renal-cell carcinoma, liver cancer, non-small cell carcinoma of the lung, cancer of the small intestine, cancer of the esophagus, melanoma, bone cancer, pancreatic cancer, skin cancer, cancer of the head or neck, cutaneous or intraocular malignant melanoma, uterine cancer, ovarian cancer, rectal cancer, cancer of the anal region, stomach cancer, testicular cancer, uterine cancer, carcinoma of the fallopian tubes, carcinoma of the endometrium, carcinoma of the cervix, carcinoma of the vagina, carcinoma of the vulva, Hodgkin's Disease, non-Hodgkin's lymphoma, cancer of the endocrine system, cancer of the thyroid gland, cancer of the parathyroid gland, cancer of the adrenal gland, sarcoma of soft tissue, cancer of the urethra, cancer of the penis, solid tumors of childhood, cancer of the bladder, cancer of the kidney or ureter, carcinoma of the renal pelvis, neoplasm of the central nervous system (CNS), primary CNS lymphoma, tumor angiogenesis, spinal axis tumor, brain stem glioma, pituitary adenoma, Kaposi's sarcoma, epidermoid cancer, squamous cell cancer, T cell lymphoma, environmentally induced cancers, combinations of said cancers, metastatic lesions of said cancers, and combinations thereof. [43] In some embodiments a patient having a disease or cancer described herein is treated with an 10 therapy (i.e., has received and/or is receiving and/or will receive during or after treatment with brequinar). In some embodiments, 10 therapy is selected from the group consisting of HSCT, cancer vaccines (alone or in combination with adoptive T cell therapy), mAbs (alone or in combination with CAR-T therapy), CAR-T therapy, and combinations thereof.

[44] According to the present disclosure, brequinar is administered to subjects treated with 10 therapy, in an amount and according to a regimen that is therapeutically effective to reduce incidence of, delay onset of, and/or reduce severity of one or more undesirable effects associated with such 10 therapy when administered absent brequinar. Administration of brequinar may also increase the efficacy of 10 therapy by increasing antigen presentation or by other mechanisms. Those skilled in the art will appreciate that brequinar may be administered in accordance with the present disclosure to subjects whether or not the particular subject(s) have experienced the relevant undesirable side effect(s). Typically, risk of a particular side effect is known based on prior clinical experience with the relevant 10 therapy or reasonably comparable 10 therapy. Ability of brequinar treatment as described herein to reduce incidence of, delay onset of, and/or reduce severity of the relevant side effect(s), or reasonably comparable side effect(s), may have been determined previously (e.g., via a clinical trial). Brequinar may be administered in accordance with the present disclosure, to any subject who has received, is receiving, or will receive, 10 therapy, in accordance with sound medical judgment.

[45] In some embodiments, a therapeutically effective amount of brequinar is submitted before initiation of 10 therapy. In some embodiments, a therapeutically effective amount of brequinar is administered at the same time as an 10 therapy (e.g., according to a dosing regimen that overlaps with that of the 10 therapy). In some embodiments, a therapeutically effective amount of brequinar is submitted after initiation of an 10 therapy, optionally after completion of one or more rounds of therapy. In some embodiments, a therapeutically effective amount of brequinar is administered after initiation of 10 therapy, but before a relevant undesirable effect (e.g., a symptom of CRS) is observed. In some embodiments, a therapeutically effective amount of brequinar is administered after one or more such relevant undesirable effects is observed in the subject.

[46] In some particular embodiments, brequinar is administered prior to initiation of 10 therapy and/or during an initial 10 therapy round (when undesirable effects have been reported to be more frequent and/or intense). In some embodiments, brequinar treatment described herein is discontinued while 10 therapy continues.

[47] In some particular embodiments, brequinar is administered after detection of one or more markers of an undesirable effect. For example, in some embodiments, brequinar is administered when fever, rash, nausea, tachypnea, tachycardia, azotemia, transaminitis, hypofibrinogenemia, or headache is detected in a patient. In some embodiments, brequinar treatment is discontinued when or if resolution of the symptoms or aberrant laboratory marker is observed.

[48] In some embodiments, patients receiving HSCT therapy in combination with a therapeutically effective amount of brequinar exhibit fewer symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving HSCT therapy and not a therapeutically effective amount of brequinar. In some embodiments, patients receiving HSCT therapy in combination with a therapeutically effective amount of brequinar exhibit less severe symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving HSCT therapy and no brequinar. In some embodiments, patients receiving HSCT therapy in combination with a therapeutically effective amount of brequinar exhibit lower grade cytokine release syndrome (e.g., as assessed by the scale described by Lee at al.) as compared to patients receiving HSCT therapy and no brequinar.

[49] In some embodiments, patients receiving HSCT therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell activation as compared to patients receiving HSCT therapy and no brequinar. In some embodiments, patients receiving HSCT therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell proliferation as compared to patients receiving HSCT therapy and no brequinar.

[50] In some embodiments, patients receiving cancer vaccine therapy in combination with a therapeutically effective amount of brequinar exhibit fewer symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving cancer vaccine therapy and no brequinar. In some embodiments, patients receiving cancer vaccine therapy in combination with a therapeutically effective amount of brequinar exhibit less severe symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving cancer vaccine therapy and no brequinar. In some embodiments, patients receiving cancer vaccine therapy in combination with a therapeutically effective amount of brequinar exhibit lower grade cytokine release syndrome (e.g., as assessed by the scale described by Lee at al.) as compared to patients receiving cancer vaccine therapy and no brequinar.

[51] In some embodiments, patients receiving cancer vaccine therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell activation as compared to patients receiving cancer vaccine therapy and no brequinar. In some embodiments, patients receiving cancer vaccine therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell proliferation as compared to patients receiving cancer vaccine therapy and no brequinar.

[52] In some embodiments, patients receiving cancer vaccine therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit fewer symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving cancer vaccine therapy and adoptive T cell therapy and no brequinar.

In some embodiments, patients receiving cancer vaccine therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit less severe symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving cancer vaccine therapy and adoptive T cell therapy and no brequinar. In some embodiments, patients receiving cancer vaccine therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit lower grade cytokine release syndrome (e.g., as assessed by the scale described by Lee at al.) as compared to patients receiving cancer vaccine therapy and adoptive T cell therapy and no brequinar.

[53] In some embodiments, patients receiving cancer vaccine therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell activation as compared to patients receiving cancer vaccine therapy and adoptive T cell therapy and no brequinar. In some embodiments, patients receiving cancer vaccine therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell proliferation as compared to patients receiving cancer vaccine therapy and adoptive T cell therapy and no brequinar.

[54] In some embodiments, patients receiving mAh therapy in combination with a therapeutically effective amount of brequinar exhibit fewer symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving mAh therapy and no brequinar. In some embodiments, patients receiving mAh therapy in combination with a therapeutically effective amount of brequinar exhibit less severe symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving mAh therapy and no brequinar. In some embodiments, patients receiving mAh therapy in combination with a therapeutically effective amount of brequinar exhibit lower grade cytokine release syndrome (e.g., as assessed by the scale described by Lee at al.) as compared to patients receiving mAh therapy and no brequinar.

[55] In some embodiments, patients receiving mAh therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell activation as compared to patients receiving mAh therapy and no brequinar. In some embodiments, patients receiving mAh therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell proliferation as compared to patients receiving mAh therapy and no brequinar.

[56] In some embodiments, patients receiving mAh therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit fewer symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving mAh therapy and adoptive T cell therapy and no brequinar. In some

embodiments, patients receiving mAh therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit less severe symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving mAh therapy and adoptive T cell therapy and no brequinar. In some embodiments, patients receiving mAh therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit lower grade cytokine release syndrome (e.g., as assessed by the scale described by Lee at al.) as compared to patients receiving mAh therapy and adoptive T cell therapy and no brequinar.

[57] In some embodiments, patients receiving mAh therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell activation as compared to patients receiving mAh therapy and adoptive T cell therapy and no brequinar. In some embodiments, patients receiving mAh therapy and adoptive T cell therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell proliferation as compared to patients receiving mAh therapy and adoptive T cell therapy and no brequinar. [58] In some embodiments, patients receiving CAR T-cell therapy in combination with a therapeutically effective amount of brequinar exhibit fewer symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving CAR T-cell therapy and no brequinar. In some embodiments, patients receiving CAR T-cell therapy in combination with a therapeutically effective amount of brequinar exhibit less severe symptoms of cytokine release syndrome or autoimmune toxicity as compared to patients receiving CAR T-cell therapy and no brequinar. In some embodiments, patients receiving CAR T-cell therapy in combination with a therapeutically effective amount of brequinar exhibit lower grade cytokine release syndrome (e.g., as assessed by the scale described by Lee at al.) as compared to patients receiving CAR T-cell therapy and no brequinar.

[59] In some embodiments, patients receiving CAR T-cell therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell activation as compared to patients receiving CAR T-cell therapy and no brequinar. In some

embodiments, patients receiving CAR T-cell therapy in combination with a therapeutically effective amount of brequinar exhibit less T cell proliferation as compared to patients receiving CAR T-cell therapy and no brequinar.

[60] Those skilled in the art will appreciate that, in some embodiments, subject(s) who receive brequinar treatment in accordance with the present disclosure may also receive, or have received one or more other therapies such as, for example, chemotherapy, anti nausea therapy, pain relief therapy, etc.

Exemplification

[61] Patients undergoing CAR T-cell therapy for the same indication will be divided into two groups. Both groups will receive the CAR-T therapy. One group will receive brequinar in addition to the CAR-T therapy. Additional standard supporting intervention to manage symptoms of CRS will be permitted. The degree of CRS exhibited by the patients will be graded based on pre-determined criteria, e.g., using the scale described by Lee at al.

[62] Patients receiving brequinar will exhibit statistically significantly lower grade symptoms of CRS. In some patients receiving brequinar, no or minimal CRS will be observed. More patients receiving brequinar will exhibit no or minimal CRS as compared to the group of patients that did not receive brequinar. Patients receiving brequinar may exhibit reduced T cell proliferation compared to patients not receiving brequinar. Patients receiving brequinar may exhibit reduced T cell activation compared to patients not receiving brequinar.

[63] Patients with hematological malignancy will be treated with brequinar, and cytokine levels and T cell subpopulations will be measured before and after treatment. The T cell cells will be analyzed through flow cytometry, next-generation sequencing of the T cell receptors, and ex-vivo studies against common antigens. Patients receiving brequinar will exhibit statistically significant reduction in T cell effector phenotype (e.g., by flow cytometry, reduced population of CD45RO+, CD57+, PD1-, CD95+, CCR7-, CD62L- cells).

Equivalents

[64] Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments of the invention described herein. The scope of the present invention is not intended to be limited to the above Description, but rather is as set forth in the following claims:

Claims

Claims We claim:

1. A method comprising administering brequinar to a patient, who is receiving or has received an immuno-oncology therapy, in an amount effective to reduce one or more side effects of said immuno-oncology therapy.

2. The method of claim 1 , wherein the side effect is cytokine release syndrome or autoimmune toxicity.

3. The method of claim 1, wherein the side effect is T cell activation.

4. The method of claim 1 , wherein the side effect is T cell proliferation.

5. A method comprising administering brequinar to a patient, who is receiving or has received an immuno-oncology therapy, in an amount effective to reduce the incidence or severity of cytokine release syndrome or autoimmune toxicity.

6. A method comprising administering brequinar to a patient, who is receiving or has received an immuno-oncology therapy, in an amount effective to reduce T cell proliferation.

7. A method comprising administering brequinar to a patient, who is receiving or has received an immuno-oncology therapy, in an amount effective to reduce T cell activation.

8. A method comprising administering brequinar to a patient, who is receiving or has received an immuno-oncology therapy, in an amount effective to reduce cytokine release.