WO2022175671A1 - Trifluoperazine for use in the treatment of neurobéastoma - Google Patents

Trifluoperazine for use in the treatment of neurobéastoma Download PDF

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Publication number
WO2022175671A1
WO2022175671A1 PCT/GB2022/050441 GB2022050441W WO2022175671A1 WO 2022175671 A1 WO2022175671 A1 WO 2022175671A1 GB 2022050441 W GB2022050441 W GB 2022050441W WO 2022175671 A1 WO2022175671 A1 WO 2022175671A1
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Prior art keywords
composition
trifluoperazine
pharmaceutically acceptable
use according
lovastatin
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PCT/GB2022/050441
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French (fr)
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David Brown
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Healx Limited
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/54—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with at least one nitrogen and one sulfur as the ring hetero atoms, e.g. sulthiame
    • A61K31/5415—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with at least one nitrogen and one sulfur as the ring hetero atoms, e.g. sulthiame ortho- or peri-condensed with carbocyclic ring systems, e.g. phenothiazine, chlorpromazine, piroxicam
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/335—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin
    • A61K31/365—Lactones
    • A61K31/366—Lactones having six-membered rings, e.g. delta-lactones

Definitions

  • This invention relates to new uses of trifluoperazine.
  • Neuroblastoma is a childhood cancer originating from the neuroblasts of the sympathetic nervous system. It is the most common solid tumour in children after brain tumours. The incidence of neuroblastoma is about 10.54 cases per 1 million per year in children younger than 15 years old. 90% of neuroblastoma cases are diagnosed by age 5.
  • MYCN is a transcription factor expressed during development that plays an important role in brain and neural development.
  • Other genetic aberrations associated with neuroblastoma include: ALK activation, TERT activation, deletion at lp36 or llql4-23, 17q gain and changes in expression or mutations of KIF1B, PHOX2B, LIN28B, TRKA, TRKB and RAS in relapsed tumours.
  • the most common primary tumour site is adrenal (47%), followed by the paraspinal sympathetic ganglia in the abdomen/ retroperitoneum (24%), thorax (15%), pelvis (3%) and neck (3%).
  • Neuroblastoma usually occurs sporadically, but familial cases with a prevalence of about 1-2% are also reported.
  • patients can be classified into four groups: extremely low risk, low risk, moderate risk and high risk. Patients that are in the low or moderate risk groups can achieve an overall survival rate >95% with the current treatment paradigm. However, patients in the high risk group have a survival rate of around 40-50%.
  • Trifluoperazine is a typical antipsychotic of the phenothiazine class. It blocks the dopaminergic D1 and D2 receptors in the brain, depresses the release of hypothalamic and hypophyseal hormones and is believed to depress the reticular activating system thus affecting basal metabolism, body temperature, wakefulness, vasomotor tone, and emesis. It is approved for the treatment of schizophrenia and anxiety disorders. Trifluoperazine has the systematic name 10-[3-(4-methylpiperazin- l-yl)propyl]-2-(trifluoromethyl)-10H-phenothiazine.
  • the present invention provides a new therapy for neuroblastoma.
  • trifluoperazine is effective in treating neuroblastoma.
  • a first aspect of the invention is a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for use in the treatment of neuroblastoma.
  • a second aspect of the invention is a kit comprising (i) at least one dose of trifluoperazine, or a pharmaceutically acceptable salt thereof; and optionally (ii) at least one dose of lovastatin, or a pharmaceutically acceptable salt thereof, for simultaneous, separate or sequential use in the treatment of neuroblastoma.
  • a third aspect of the invention is a use of a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for use in the treatment of neuroblastoma.
  • a fourth aspect of the invention provides a method of treating neuroblastoma comprising administering the patient with a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof.
  • FIGS 1A-F show the results from the trifluoperazine monotherapy in vitro testing.
  • Figures 2A-F show the results from the lovastatin monotherapy in vitro testing.
  • Figures 3A-C show the cell death and viability results from trifluoperazine and lovastatin in vitro combination testing.
  • Xenografts based on conventional cancer cell lines have been used for decades and while this model system can provide valuable data, cultured cell lines that have adapted to the in vitro microenvironment often differ from the original tumour found in patients.
  • Patient-derived xenografts are generated from the subcutaneous or orthotopic implantation of intact patient tumor fragments directly into immunodeficient mice or rats, thereby avoiding in vitro adaptation.
  • PDXs have been found to recapitulate the histopathological hallmarks, genetic pathways and mutational patterns of the corresponding patient tumors.
  • the in vitro data herein has been generated using the PDX1, PDX2, and PDX3 cell models, as described in Braekeveldt et al, Int. J. Cancer, 2015, E252-E261.
  • trifluoperazine inhibits cell viability and increases cell death in neuroblastoma patient- derived xenograft tumours, and is therefore effective at treating neuroblastoma.
  • treatment or “treating” as used herein, we refer to therapeutic (curative) treatment, which includes reducing the size of a neuroblastoma tumour or stopping a neuroblastoma tumour increasing in size.
  • Patient and “subject” are used interchangeably and refer to the subject that is to be administered the composition comprising lovastatin.
  • the subject is a human.
  • the patient is a paediatric patient, preferably a paediatric patient 15 years of age and younger, more preferably 10 years of age or younger, most preferably 5 years of age and younger.
  • the methods of classification of neuroblastoma tumours are complex and are based on a combination of different factors.
  • Described below is a method of classifying neuroblastoma tumours according to the INRGSS system.
  • the characteristics described below for each stage are exemplary only.
  • There are other established systems for classifying the tumours such as the INSS system, among others.
  • the medical practitioner is skilled in diagnosing and would be able to determine the stage of the tumour.
  • the tumours of neuroblastoma may be described as follows:
  • Stage LI The tumour is located only in the area where it started; no image defined risk factors (IDRFs) are found on imaging scans, such as CT or MRI.
  • IDRFs image defined risk factors
  • Stage L2 The tumour has spread to the tissue nearby the area it started; IDRFs are found on imaging scans, such as CT or MRI.
  • Stage M The tumour has spread to other parts of the body (except stage MS, see below).
  • Stage MS The tumour has spread to only the skin, liver, and/or bone marrow (less than 10% bone marrow involvement) in patients younger than 18 months.
  • the compounds and compositions of the invention can be used to treat any of the tumours described above.
  • the subject may be classified as very low, low, moderate or high risk.
  • the subject is classified as moderate or high risk, more preferably high risk.
  • Very low-risk neuroblastoma refers to Stage L1/L2 with ganglioneuroma maturing or ganglioneuroblastoma intermixed histology, Stage LI with non-amplified MYCN, or Stage MS in children younger than 18 months of age with no chromosome llq aberration.
  • Low-risk neuroblastoma refers to Stage L2 in children younger than 18 months of age with no llq aberration, Stage L2 in children older than 18 months of age with ganglioneuroblastoma nodular or neuroblastoma with differentiating histology and no llq aberration, Stage M in children younger than 18 months without MYCN amplification and hyperdiploidy.
  • Moderate-risk neuroblastoma refers to Stage L2 in children younger than 18 months without MYCN amplification with llq aberration, Stage L2 in children older than 18 months with ganglioneuroblastoma nodular or neuroblastoma with differentiating histology with llq aberration, Stage L2 in children older than 18 months with ganglioneuroblastoma nodular or neuroblastoma with poorly differentiated or undifferentiated histology, Stage M in children younger than 12 months with diploidy, or Stage M in children 12 months to 18 months with diploidy.
  • High-risk neuroblastoma refers to Stage LI with MYCN amplification, Stage L2 with MYCN amplification, Stage M in children younger than 18 months of age with MYCN amplification, Stage M in children with older than 18 months, Stage MS in children younger than 18 months with llq aberration, or Stage MS in children younger than 18 months of age with MYCN amplification.
  • a composition comprising trifluoperazine is used for the treatment of neuroblastoma, wherein the patient has had or is going to have surgery to remove some or all of the neuroblastoma tumour. This may be particularly advantageous if the neuroblastoma is large and/or expands across tissue boundaries, so it is difficult to remove it all by surgery and/or a quick removal of at least some of it is desired/beneficial.
  • Surgery has its normal meaning in the art. Surgery is an invasive technique with the fundamental principle of physical intervention on organs/organ systems/tissues for diagnostic or therapeutic reasons.
  • a pharmaceutically acceptable salt is a salt with a pharmaceutically acceptable acid or base.
  • Pharmaceutically acceptable acids include both inorganic acids such as hydrochloric, sulphuric, phosphoric, diphosphoric, hydrobromic or nitric acid and organic acids such as fendizoic, citric, fumaric, maleic, malic, ascorbic, succinic, tartaric, benzoic, acetic, methanesulfonic, ethanesulfonic, salicylic, stearic, benzenesulfonic or p-toluenesulfonic acid.
  • Pharmaceutically acceptable bases include alkali metal (e.g. sodium or potassium) and alkali earth metal (e.g.
  • the pharmaceutically acceptable salt of trifluoperazine is hydrochloride.
  • the present invention is directed to a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for use in the treatment of neuroblastoma, wherein trifluoperazine is the only active agent in the composition.
  • trifluoperazine is the only active agent in the composition.
  • active agent it is meant that the composition does not contain other components which may be used in the treatment of neuroblastoma.
  • the present invention is directed to a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, and lovastatin, or a pharmaceutically acceptable salt thereof, for use in the treatment or of neuroblastoma.
  • the present invention is directed to a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for use in combination with a second composition comprising lovastatin, or a pharmaceutically acceptable salt thereof, wherein the two compositions are administered to the subject simultaneously, separately or sequentially.
  • trifluoperazine has been identified as showing synergistic effects in the treatment of neuroblastoma, when used in combination with trifluoperazine.
  • Lovastatin is a member of the statin class of drugs, it is a fermentation product of Aspergillus terreus. Lovastatin is a lipid lowering drug that acts via inhibiting HMG- CoA reductase, an early and rate limiting step of cholesterol biosynthesis. It is approved for treatment of hyperlipidemias, atherosclerosis, coronary disease and hypercholesterolemia. Lovastatin is formulated as a prodrug in the form of an inactive but cell permeant beta lactone. In vivo and in cells the beta lactone is converted to the active beta hydroxy acid form which is less able to pass through the cell membrane.
  • Lovastatin has the following name: (2S)- (lS,3R,7S,8S,8aR)-l,2,3,7,8,8a-hexahydro- 3,7-dimethyl-8-[2-[(2R,4R)-tetrahydro-4-hydroxy-6-oxo-2H-pyran-2-yl]ethyl]-l- naphthalenyl ester, 2-methylbutanoic acid.
  • compositions of the invention may contain a pharmaceutically acceptable carrier.
  • pharmaceutically acceptable carrier is meant any diluent or excipient, such as fillers or binders, that is compatible with the other ingredients of the compositions, and which is not deleterious to the recipient.
  • the pharmaceutically acceptable carrier can be selected on the basis of the desired route of administration, in accordance with standard pharmaceutical practices.
  • the compositions may be administered in a variety of dosage forms.
  • the compositions may be formulated in a format suitable for oral, rectal, parenteral, intranasal or transdermal administration or administration by inhalation or by suppository.
  • the compositions may be administered orally, for example as tablets, troches, lozenges, aqueous or oily suspensions, dispersible powders or granules.
  • the compositions are formulated such that it is suitable for oral administration, for example tablets and capsules.
  • Tablets and capsules may be prepared with binding agents, for example, syrup, acacia, gelatin, sorbitol, tragacanth, celluloses or polyvinylpyrrolidone; fillers, such as lactose, sucrose, corn starch, calcium phosphate, sorbitol, or glycine; lubricants, such as magnesium stearate, talc, polyethylene glycol, or silica; and surfactants, such as sodium lauryl sulfate.
  • binding agents for example, syrup, acacia, gelatin, sorbitol, tragacanth, celluloses or polyvinylpyrrolidone
  • fillers such as lactose, sucrose, corn starch, calcium phosphate, sorbitol, or glycine
  • lubricants such as magnesium stearate, talc, polyethylene glycol, or silica
  • surfactants such as sodium lauryl sulfate.
  • Liquid compositions may contain conventional additives such as suspending agents, for example sorbitol syrup, methyl cellulose, sugar syrup, gelatin, carboxymethyl-cellulose, or edible fats; emulsifying agents and surfactants such as lecithin, or acacia; vegetable oils such as almond oil, coconut oil, cod liver oil, or peanut oil; preservatives such as butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT).
  • suspending agents for example sorbitol syrup, methyl cellulose, sugar syrup, gelatin, carboxymethyl-cellulose, or edible fats
  • emulsifying agents and surfactants such as lecithin, or acacia
  • vegetable oils such as almond oil, coconut oil, cod liver oil, or peanut oil
  • preservatives such as butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT).
  • Liquid compositions may be encapsulated in, for example,
  • compositions may also be administered parenterally, whether subcutaneously, intravenously, intramuscularly, intrasternally, transdermally or by infusion techniques.
  • compositions may also be administered by inhalation.
  • inhaled medications are their direct delivery to the area of rich blood supply in comparison to many medications taken by oral route. Thus, the absorption is very rapid as the alveoli have an enormous surface area and rich blood supply and first pass metabolism is bypassed.
  • the present invention also provides an inhalation device containing the compositions of the present invention.
  • said device is a metered dose inhaler (MDI), which contains a pharmaceutically acceptable chemical propellant to push the medication out of the inhaler.
  • MDI metered dose inhaler
  • compositions may also be administered by intranasal administration.
  • the nasal cavity's highly permeable tissue is very receptive to medication and absorbs it quickly and efficiently.
  • Nasal drug delivery is less painful and invasive than injections, generating less anxiety among patients. By this method absorption is very rapid and first pass metabolism is usually bypassed, thus reducing inter-patient variability.
  • the present invention also provides an intranasal device containing the composition according to the present invention.
  • compositions may also be administered by transdermal administration.
  • transdermal and transmucosal patches for topical delivery, transdermal and transmucosal patches, creams, ointments, jellies, solutions or suspensions may be employed.
  • the present invention therefore also provides a transdermal patch containing the compositions.
  • the compositions may also be administered by sublingual administration.
  • the present invention therefore also provides a sub-lingual tablet comprising the compositions.
  • compositions may also be formulated with an agent which reduces degradation of the substance by processes other than the normal metabolism of the patient, such as anti-bacterial agents, or inhibitors of protease enzymes which might be the present in the patient or in commensural or parasite organisms living on or within the patient, and which are capable of degrading the compound.
  • an agent which reduces degradation of the substance by processes other than the normal metabolism of the patient such as anti-bacterial agents, or inhibitors of protease enzymes which might be the present in the patient or in commensural or parasite organisms living on or within the patient, and which are capable of degrading the compound.
  • Liquid dispersions for oral administration may be syrups, emulsions and suspensions.
  • Suspensions and emulsions may contain as carrier, for example a natural gum, agar, sodium alginate, pectin, methylcellulose, carboxymethylcellulose, or polyvinyl alcohol.
  • the suspension or solutions for intramuscular injections may contain, together with the active compound, a pharmaceutically acceptable carrier, e.g. sterile water, olive oil, ethyl oleate, glycols, e.g. propylene glycol, and if desired, a suitable amount of lidocaine hydrochloride.
  • Solutions for injection or infusion may contain as carrier, for example, sterile water or preferably they may be in the form of sterile, aqueous, isotonic saline solutions.
  • compositions are administered in an effective amount to treat neuroblastoma.
  • An effective dose will be apparent to one skilled in the art, and is dependent on a number of factors including age, sex, weigh, which the medical practitioner will be capable of determining.
  • compositions and kits of the present invention provide for the administration of more than one drug, and they can be administered simultaneously, sequentially or separately. It is not necessary that they are packed together (but this is one embodiment of the invention). It is also not necessary that they are administered at the same time.
  • “separate” administration means that the drugs are administered as part of the same overall dosage regimen (which could comprise a number of days), but preferably on the same day.
  • “simultaneously” means that the drugs are to be taken together or formulated as a single composition.
  • “sequentially” means that the drugs are administered at about the same time, and preferably within about 1 hour of each other.
  • the drugs are administered simultaneously i.e. taken together or formulated as a single composition. Most preferably, they are formulated as a single composition.
  • the composition comprises 2 mg to 40 mg, more preferably 4 mg to 20 mg, yet more preferably 15 to 20 mg trifluoperazine.
  • the composition may be administered once a day, twice a day, three times a day or four times a day.
  • the composition is administered at least once a day.
  • it is administered as a single daily dose.
  • the single daily dose is 2 mg to 40 mg, more preferably 4 mg to 20 mg, yet more preferably 15 to 20 mg of trifluoperazine.
  • Exemplary doses are 5, 10, 15, or 20 mg of trifluoperazine.
  • the composition further comprises lovastatin or a pharmaceutically acceptable salt thereof, wherein the composition comprises 1 mg to 100 mg, preferably 5 mg to 90 mg, more preferably 10 mg to 80 mg, yet more preferably 20 to 60 mg of lovastatin.
  • the lovastatin or a pharmaceutically acceptable salt thereof is administered in a second composition, wherein the second composition comprises 1 mg to 100 mg, preferably 5 mg to 90 mg, more preferably 10 mg to 80 mg, yet more preferably 20 to 60 mg of lovastatin.
  • compositions comprising trifluoperazine and the second composition are a single daily dose.
  • the two compositions are administered simultaneously i.e. trifluoperazine and lovastatin are taken together.
  • the compositions may also be administered sequentially i.e. at about the same time, and preferably within about 1 hour of each other.
  • the composition is administered twice daily.
  • each dose is 1 mg to 20 mg, more preferably 2 mg to 10 mg, yet more preferably 7.5 mg to 10 mg of trifluoperazine.
  • Exemplary doses are 1, 5, and 10 mg of trifluoperazine.
  • each dose comprises 0.5 to 50 mg, preferably 2.5 to 45 mg, more preferably 5 to 40 mg, yet more preferably 10 to 30 mg of lovastatin.
  • each dose comprises 0.5 to 50 mg, preferably 2.5 to 45 mg, more preferably 5 to 40 mg, yet more preferably 10 to 30 mg of lovastatin.
  • Each dose or composition may be administered separately or sequentially i.e. at about the same time, and preferably within about 1 hour of each other.
  • the composition is administered three times daily.
  • each dose is 0.6 mg to 15 mg, more preferably 1.3 mg to 6.5 mg, yet more preferably 5 mg to 6.5 mg of trifluoperazine.
  • Exemplary doses are 1, 3, or 5 mg of trifluoperazine.
  • each dose comprises 0.3 mg to 33 mg, more preferably 1.5 mg to 30 mg, more preferably 3 mg to 30 mg, yet more preferably 6 mg to 20 mg of lovastatin.
  • each dose comprises 0.3 mg to 33 mg, more preferably 1.5 mg to 30 mg, more preferably 3 mg to 30 mg, yet more preferably 6 to 20 mg of lovastatin.
  • Each dose or composition may be administered separately or sequentially i.e. at about the same time, and preferably within about 1 hour of each other.
  • the dosage regime is such that the total daily dosage of trifluoperazine does not exceed 40 mg.
  • the effective dose of trifluoperazine results in a concentration of 1 to 10 pM, preferably 1 to 5 pM, more preferably 1 to 4 pM in cells.
  • the composition comprising trifluoperazine is used in a chronic dosage regime i.e. chronic, long-term treatment.
  • a chronic dosage regime i.e. chronic, long-term treatment.
  • the regime lasts for at least one month, suitably at least two months, such as at least three months.
  • the present invention also relates to a kit comprising: (i) at least one dose of trifluoperazine, or a pharmaceutically acceptable salt thereof; and optionally (ii) at least one dose of lovastatin, or a pharmaceutically acceptable salt thereof, for simultaneous, separate or sequential use in the treatment of neuroblastoma.
  • the present invention also relates to the use of a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for use in the treatment of neuroblastoma.
  • This embodiment of the invention may have any of the preferred features described above.
  • the present invention also relates to a method of treating -neuroblastoma comprising administering the patient with a composition comprising trifluoperazine or a pharmaceutically acceptable salt thereof.
  • This embodiment of the invention may have any of the preferred features described above.
  • the method of administration may be according to any of the routes described above.
  • the present invention further relates to a method of treating -neuroblastoma comprising administering the patient with a composition comprising trifluoperazine or a pharmaceutically acceptable salt thereof, and a second composition comprising lovastatin, or a pharmaceutically acceptable salt thereof, wherein the two compositions are administered to the patient simultaneously, separately or sequentially.
  • This embodiment of the invention may have any of the preferred features described above.
  • the method of administration may be according to any of the routes described above.
  • the present invention also embraces prodrugs which react in vivo to give a compound of the present invention.
  • Example 1 Monotherapy in vitro drug testing of trifluoperazine and lovastatin
  • tumours were grown in male or female NSG mice, mice were housed under pathogen free conditions and given access to food and water ab libitum. Animals were sacrificed, tumour tissues excised and digested for 45 mins at 37°C with Liberase (0.15mg/ml).
  • Dissociated tissue was passed through a 70pm cell strainer and cultured in non-adherent plates as tumour spheroids at 37°C in a humidified atmosphere with 5% CO2 in the following culture medium: Dulbecco's Modified Eagle's medium DMEM/F12 medium with glutamine, 100 IU/ml penicillin and 100 pg/ml of streptomycin, 2% B27 supplement, 40 ng/ml of basic fibroblast growth factor (FGF) 2 and 20 ng/ml of epidermal growth factor (EGF). Directly upon seeding cells were treated with the compounds solubilised in DMSO, then cultured for 3 or 7 days.
  • Dulbecco's Modified Eagle's medium DMEM/F12 medium with glutamine, 100 IU/ml penicillin and 100 pg/ml of streptomycin, 2% B27 supplement, 40 ng/ml of basic fibroblast growth factor (FGF) 2 and 20 ng/ml of epidermal growth factor
  • Cell viability was quantified using the CellTiter-Glo ® luminescence Cell Viability Assay. Using this assay the number of metabolically active viable cells present in a culture can be determined based on the concentration of ATP. The luminescent signal produced is proportional to the amount of ATP present.
  • Lovastatin and trifluoperazine hydrochloride had a purity of >95%. Drugs were tested in triplicate, at a minimum of 6 concentrations, top concentration of IOmM (free- base equivalent). Cell viability readouts were normalized to DMSO treated controls, concentration-response curves were plotted and IC50 and R2 values were calculated using GraphPad Prism 8.4.3. Results
  • Viable cells in the culture were quantified using the trypan blue staining assay.
  • Trypan blue is an azo dye that is cell membrane impermeable that can only enter dead cells that have a permeable membrane. The dye binds to intracellular proteins and therefore dead cells are stained blue. The number of live (unstained) and dead (stained) cells were then quantified, and the percentage of viable cells calculated.
  • Annexin V/PI staining cells were incubated with fluorescent annexin V and PI, a human vascular anti-coagulant that binds to phospholipid phosphatidylserine (PS).
  • PS is normally found on the inner leaflets of the plasma membrane, during apoptosis these move to the outer leaflet of the plasma membrane. Therefore, annexin V only binds to apoptotic cells.
  • PI is a red fluorescent stain that binds to DNA and is impermeable to live cells, therefore only binds to dead cells.
  • Annexin V/PI assay was carried out according to manufacturer's instructions.
  • Caspase 3 an apoptosis marker was quantified using the NucView® Caspase-3 assay kit in live cells according to manufacturer's instructions. Cells were counted on a FACSverse flow cytometer and populations gated and quantified.
  • Concentration response combination studies were carried out in the PDX 1, 2 and 3 cell models.
  • Cells were cultured using the same protocol as described for the monotherapy studies. At seeding, cells were treated with lovastatin combined with trifluoperazine in a 6x6 concentration matrix of increasing concentrations of both drugs. Cells were cultured for 3 or 7 days; cell viability was quantified using the CellTiter-Glo® luminescence Cell Viability Assay.
  • Lovastatin and trifluoperazine hydrochloride had a purity of >95%. Drugs were tested in triplicate, the top concentration of lovastatin was 20pM, top concentration of trifluoperazine was 5pM (free-base equivalent).
  • Trifluoperazine inhibits the cell viability and increases cell death in neuroblastoma cell lines, and is therefore effective at treating neuroblastoma.
  • the reduction in cell viability can be further enhanced when a combination of trifluoperazine and lovastatin is used.
  • the combination treatment leads to synergistic increases (i.e. greater than the expected additive values) in cell death and reduction in cell viability, and this synergy is quantified by the ZIP synergy scores.

Abstract

The present invention relates to compositions comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for use in the treatment of neuroblastoma.

Description

TRIFLUOPERAZINE FOR USE IN THE TREATMENT OF NEUROBEASTOMA
Field of the invention
This invention relates to new uses of trifluoperazine.
Background of the invention
Neuroblastoma is a childhood cancer originating from the neuroblasts of the sympathetic nervous system. It is the most common solid tumour in children after brain tumours. The incidence of neuroblastoma is about 10.54 cases per 1 million per year in children younger than 15 years old. 90% of neuroblastoma cases are diagnosed by age 5.
The genetic causation of neuroblastoma, like most cancers, is complex and heterogeneous. A common event in patients with high risk neuroblastoma and associated with poor prognosis is the amplification of the MYCN gene. MYCN is a transcription factor expressed during development that plays an important role in brain and neural development. Other genetic aberrations associated with neuroblastoma include: ALK activation, TERT activation, deletion at lp36 or llql4-23, 17q gain and changes in expression or mutations of KIF1B, PHOX2B, LIN28B, TRKA, TRKB and RAS in relapsed tumours. The most common primary tumour site is adrenal (47%), followed by the paraspinal sympathetic ganglia in the abdomen/ retroperitoneum (24%), thorax (15%), pelvis (3%) and neck (3%). Neuroblastoma usually occurs sporadically, but familial cases with a prevalence of about 1-2% are also reported. Based on a number of factors including age at diagnosis, histopathological classification and the genetic profile of the tumour, patients can be classified into four groups: extremely low risk, low risk, moderate risk and high risk. Patients that are in the low or moderate risk groups can achieve an overall survival rate >95% with the current treatment paradigm. However, patients in the high risk group have a survival rate of around 40-50%.
At present there is no effective therapy to treat neuroblastoma patients who are in the high risk category. The current treatment path for patients that have high risk tumours is intensive and multimodal; they receive high-dose chemotherapy, radiotherapy, surgery, myeloablative therapy and stem cell transplant, isotretinoin differentiation therapy and immunotherapy (anti-GD2, IL-l/GM-CSF). Despite multiple therapeutic options for these patients the survival rate is still 40-50%, meaning there is a high unmet need for new therapeutics for patients in this risk category, that can prolong life with reduced toxicity.
Trifluoperazine is a typical antipsychotic of the phenothiazine class. It blocks the dopaminergic D1 and D2 receptors in the brain, depresses the release of hypothalamic and hypophyseal hormones and is believed to depress the reticular activating system thus affecting basal metabolism, body temperature, wakefulness, vasomotor tone, and emesis. It is approved for the treatment of schizophrenia and anxiety disorders. Trifluoperazine has the systematic name 10-[3-(4-methylpiperazin- l-yl)propyl]-2-(trifluoromethyl)-10H-phenothiazine.
Summary of the invention
The present invention provides a new therapy for neuroblastoma. As will be evident from the in vitro data presented below, trifluoperazine is effective in treating neuroblastoma.
Accordingly, a first aspect of the invention is a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for use in the treatment of neuroblastoma.
A second aspect of the invention is a kit comprising (i) at least one dose of trifluoperazine, or a pharmaceutically acceptable salt thereof; and optionally (ii) at least one dose of lovastatin, or a pharmaceutically acceptable salt thereof, for simultaneous, separate or sequential use in the treatment of neuroblastoma.
A third aspect of the invention is a use of a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for use in the treatment of neuroblastoma.
A fourth aspect of the invention provides a method of treating neuroblastoma comprising administering the patient with a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof.
Description of the figures
Figures 1A-F show the results from the trifluoperazine monotherapy in vitro testing.
Figures 2A-F show the results from the lovastatin monotherapy in vitro testing.
Figures 3A-C show the cell death and viability results from trifluoperazine and lovastatin in vitro combination testing.
Detailed description
Xenografts based on conventional cancer cell lines have been used for decades and while this model system can provide valuable data, cultured cell lines that have adapted to the in vitro microenvironment often differ from the original tumour found in patients. Patient-derived xenografts (PDXs) are generated from the subcutaneous or orthotopic implantation of intact patient tumor fragments directly into immunodeficient mice or rats, thereby avoiding in vitro adaptation. Importantly, PDXs have been found to recapitulate the histopathological hallmarks, genetic pathways and mutational patterns of the corresponding patient tumors. The in vitro data herein has been generated using the PDX1, PDX2, and PDX3 cell models, as described in Braekeveldt et al, Int. J. Cancer, 2015, E252-E261.
In the present invention, and as demonstrated by the in vitro data herein, trifluoperazine inhibits cell viability and increases cell death in neuroblastoma patient- derived xenograft tumours, and is therefore effective at treating neuroblastoma.
By the term "treatment" or "treating" as used herein, we refer to therapeutic (curative) treatment, which includes reducing the size of a neuroblastoma tumour or stopping a neuroblastoma tumour increasing in size.
"Patient" and "subject" are used interchangeably and refer to the subject that is to be administered the composition comprising lovastatin. Preferably the subject is a human. In one embodiment the patient is a paediatric patient, preferably a paediatric patient 15 years of age and younger, more preferably 10 years of age or younger, most preferably 5 years of age and younger.
The methods of classification of neuroblastoma tumours are complex and are based on a combination of different factors.
Described below is a method of classifying neuroblastoma tumours according to the INRGSS system. The characteristics described below for each stage are exemplary only. There are other established systems for classifying the tumours, such as the INSS system, among others. The medical practitioner is skilled in diagnosing and would be able to determine the stage of the tumour. According to the INRGSS system, the tumours of neuroblastoma may be described as follows:
Stage LI : The tumour is located only in the area where it started; no image defined risk factors (IDRFs) are found on imaging scans, such as CT or MRI.
Stage L2: The tumour has spread to the tissue nearby the area it started; IDRFs are found on imaging scans, such as CT or MRI.
Stage M : The tumour has spread to other parts of the body (except stage MS, see below).
Stage MS: The tumour has spread to only the skin, liver, and/or bone marrow (less than 10% bone marrow involvement) in patients younger than 18 months.
Suitably the compounds and compositions of the invention can be used to treat any of the tumours described above.
Suitably the subject may be classified as very low, low, moderate or high risk. Preferably, the subject is classified as moderate or high risk, more preferably high risk. Very low-risk neuroblastoma refers to Stage L1/L2 with ganglioneuroma maturing or ganglioneuroblastoma intermixed histology, Stage LI with non-amplified MYCN, or Stage MS in children younger than 18 months of age with no chromosome llq aberration.
Low-risk neuroblastoma refers to Stage L2 in children younger than 18 months of age with no llq aberration, Stage L2 in children older than 18 months of age with ganglioneuroblastoma nodular or neuroblastoma with differentiating histology and no llq aberration, Stage M in children younger than 18 months without MYCN amplification and hyperdiploidy.
Moderate-risk neuroblastoma refers to Stage L2 in children younger than 18 months without MYCN amplification with llq aberration, Stage L2 in children older than 18 months with ganglioneuroblastoma nodular or neuroblastoma with differentiating histology with llq aberration, Stage L2 in children older than 18 months with ganglioneuroblastoma nodular or neuroblastoma with poorly differentiated or undifferentiated histology, Stage M in children younger than 12 months with diploidy, or Stage M in children 12 months to 18 months with diploidy.
High-risk neuroblastoma refers to Stage LI with MYCN amplification, Stage L2 with MYCN amplification, Stage M in children younger than 18 months of age with MYCN amplification, Stage M in children with older than 18 months, Stage MS in children younger than 18 months with llq aberration, or Stage MS in children younger than 18 months of age with MYCN amplification.
In one embodiment, a composition comprising trifluoperazine is used for the treatment of neuroblastoma, wherein the patient has had or is going to have surgery to remove some or all of the neuroblastoma tumour. This may be particularly advantageous if the neuroblastoma is large and/or expands across tissue boundaries, so it is difficult to remove it all by surgery and/or a quick removal of at least some of it is desired/beneficial.
The term "surgery" has its normal meaning in the art. Surgery is an invasive technique with the fundamental principle of physical intervention on organs/organ systems/tissues for diagnostic or therapeutic reasons.
As used herein, a pharmaceutically acceptable salt is a salt with a pharmaceutically acceptable acid or base. Pharmaceutically acceptable acids include both inorganic acids such as hydrochloric, sulphuric, phosphoric, diphosphoric, hydrobromic or nitric acid and organic acids such as fendizoic, citric, fumaric, maleic, malic, ascorbic, succinic, tartaric, benzoic, acetic, methanesulfonic, ethanesulfonic, salicylic, stearic, benzenesulfonic or p-toluenesulfonic acid. Pharmaceutically acceptable bases include alkali metal (e.g. sodium or potassium) and alkali earth metal (e.g. calcium or magnesium) hydroxides and organic bases such as alkyl amines, aryl amines or heterocyclic amines. In a preferred embodiment, the pharmaceutically acceptable salt of trifluoperazine is hydrochloride. In an alternative embodiment, the present invention is directed to a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for use in the treatment of neuroblastoma, wherein trifluoperazine is the only active agent in the composition. By only active agent it is meant that the composition does not contain other components which may be used in the treatment of neuroblastoma.
In an alternative embodiment, the present invention is directed to a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, and lovastatin, or a pharmaceutically acceptable salt thereof, for use in the treatment or of neuroblastoma.
In an alternative embodiment, the present invention is directed to a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for use in combination with a second composition comprising lovastatin, or a pharmaceutically acceptable salt thereof, wherein the two compositions are administered to the subject simultaneously, separately or sequentially.
As shown by the below in vitro data, trifluoperazine has been identified as showing synergistic effects in the treatment of neuroblastoma, when used in combination with trifluoperazine.
Lovastatin is a member of the statin class of drugs, it is a fermentation product of Aspergillus terreus. Lovastatin is a lipid lowering drug that acts via inhibiting HMG- CoA reductase, an early and rate limiting step of cholesterol biosynthesis. It is approved for treatment of hyperlipidemias, atherosclerosis, coronary disease and hypercholesterolemia. Lovastatin is formulated as a prodrug in the form of an inactive but cell permeant beta lactone. In vivo and in cells the beta lactone is converted to the active beta hydroxy acid form which is less able to pass through the cell membrane. Lovastatin has the following name: (2S)- (lS,3R,7S,8S,8aR)-l,2,3,7,8,8a-hexahydro- 3,7-dimethyl-8-[2-[(2R,4R)-tetrahydro-4-hydroxy-6-oxo-2H-pyran-2-yl]ethyl]-l- naphthalenyl ester, 2-methylbutanoic acid.
The compositions of the invention may contain a pharmaceutically acceptable carrier. By "pharmaceutically acceptable carrier" is meant any diluent or excipient, such as fillers or binders, that is compatible with the other ingredients of the compositions, and which is not deleterious to the recipient. The pharmaceutically acceptable carrier can be selected on the basis of the desired route of administration, in accordance with standard pharmaceutical practices.
In the present invention, the compositions may be administered in a variety of dosage forms. In one embodiment, the compositions may be formulated in a format suitable for oral, rectal, parenteral, intranasal or transdermal administration or administration by inhalation or by suppository. The compositions may be administered orally, for example as tablets, troches, lozenges, aqueous or oily suspensions, dispersible powders or granules. Preferably, the compositions are formulated such that it is suitable for oral administration, for example tablets and capsules. Tablets and capsules may be prepared with binding agents, for example, syrup, acacia, gelatin, sorbitol, tragacanth, celluloses or polyvinylpyrrolidone; fillers, such as lactose, sucrose, corn starch, calcium phosphate, sorbitol, or glycine; lubricants, such as magnesium stearate, talc, polyethylene glycol, or silica; and surfactants, such as sodium lauryl sulfate. Liquid compositions may contain conventional additives such as suspending agents, for example sorbitol syrup, methyl cellulose, sugar syrup, gelatin, carboxymethyl-cellulose, or edible fats; emulsifying agents and surfactants such as lecithin, or acacia; vegetable oils such as almond oil, coconut oil, cod liver oil, or peanut oil; preservatives such as butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT). Liquid compositions may be encapsulated in, for example, gelatin to provide a unit dosage form.
The compositions may also be administered parenterally, whether subcutaneously, intravenously, intramuscularly, intrasternally, transdermally or by infusion techniques.
The compositions may also be administered by inhalation. An advantage of inhaled medications is their direct delivery to the area of rich blood supply in comparison to many medications taken by oral route. Thus, the absorption is very rapid as the alveoli have an enormous surface area and rich blood supply and first pass metabolism is bypassed.
The present invention also provides an inhalation device containing the compositions of the present invention. Typically said device is a metered dose inhaler (MDI), which contains a pharmaceutically acceptable chemical propellant to push the medication out of the inhaler.
The compositions may also be administered by intranasal administration. The nasal cavity's highly permeable tissue is very receptive to medication and absorbs it quickly and efficiently. Nasal drug delivery is less painful and invasive than injections, generating less anxiety among patients. By this method absorption is very rapid and first pass metabolism is usually bypassed, thus reducing inter-patient variability. Further, the present invention also provides an intranasal device containing the composition according to the present invention.
The compositions may also be administered by transdermal administration. For topical delivery, transdermal and transmucosal patches, creams, ointments, jellies, solutions or suspensions may be employed. The present invention therefore also provides a transdermal patch containing the compositions. The compositions may also be administered by sublingual administration. The present invention therefore also provides a sub-lingual tablet comprising the compositions.
The compositions may also be formulated with an agent which reduces degradation of the substance by processes other than the normal metabolism of the patient, such as anti-bacterial agents, or inhibitors of protease enzymes which might be the present in the patient or in commensural or parasite organisms living on or within the patient, and which are capable of degrading the compound.
Liquid dispersions for oral administration may be syrups, emulsions and suspensions.
Suspensions and emulsions may contain as carrier, for example a natural gum, agar, sodium alginate, pectin, methylcellulose, carboxymethylcellulose, or polyvinyl alcohol. The suspension or solutions for intramuscular injections may contain, together with the active compound, a pharmaceutically acceptable carrier, e.g. sterile water, olive oil, ethyl oleate, glycols, e.g. propylene glycol, and if desired, a suitable amount of lidocaine hydrochloride.
Solutions for injection or infusion may contain as carrier, for example, sterile water or preferably they may be in the form of sterile, aqueous, isotonic saline solutions.
In an embodiment of the invention, the compositions are administered in an effective amount to treat neuroblastoma. An effective dose will be apparent to one skilled in the art, and is dependent on a number of factors including age, sex, weigh, which the medical practitioner will be capable of determining.
The compositions and kits of the present invention provide for the administration of more than one drug, and they can be administered simultaneously, sequentially or separately. It is not necessary that they are packed together (but this is one embodiment of the invention). It is also not necessary that they are administered at the same time. As used herein, "separate" administration means that the drugs are administered as part of the same overall dosage regimen (which could comprise a number of days), but preferably on the same day. As used herein "simultaneously" means that the drugs are to be taken together or formulated as a single composition. As used herein, "sequentially" means that the drugs are administered at about the same time, and preferably within about 1 hour of each other.
Preferably, the drugs are administered simultaneously i.e. taken together or formulated as a single composition. Most preferably, they are formulated as a single composition. In a preferred embodiment, the composition comprises 2 mg to 40 mg, more preferably 4 mg to 20 mg, yet more preferably 15 to 20 mg trifluoperazine. The composition may be administered once a day, twice a day, three times a day or four times a day.
In an embodiment of the invention, the composition is administered at least once a day. Preferably it is administered as a single daily dose. Preferably the single daily dose is 2 mg to 40 mg, more preferably 4 mg to 20 mg, yet more preferably 15 to 20 mg of trifluoperazine. Exemplary doses are 5, 10, 15, or 20 mg of trifluoperazine.
In another embodiment, the composition further comprises lovastatin or a pharmaceutically acceptable salt thereof, wherein the composition comprises 1 mg to 100 mg, preferably 5 mg to 90 mg, more preferably 10 mg to 80 mg, yet more preferably 20 to 60 mg of lovastatin.
Alternatively the lovastatin or a pharmaceutically acceptable salt thereof is administered in a second composition, wherein the second composition comprises 1 mg to 100 mg, preferably 5 mg to 90 mg, more preferably 10 mg to 80 mg, yet more preferably 20 to 60 mg of lovastatin.
Suitably the composition comprising trifluoperazine and the second composition are a single daily dose. Suitably the two compositions are administered simultaneously i.e. trifluoperazine and lovastatin are taken together. The compositions may also be administered sequentially i.e. at about the same time, and preferably within about 1 hour of each other.
In an embodiment of the invention, the composition is administered twice daily. Preferably each dose is 1 mg to 20 mg, more preferably 2 mg to 10 mg, yet more preferably 7.5 mg to 10 mg of trifluoperazine. Exemplary doses are 1, 5, and 10 mg of trifluoperazine. When the composition further comprises lovastatin, or a pharmaceutically acceptable salt thereof, as described above, each dose comprises 0.5 to 50 mg, preferably 2.5 to 45 mg, more preferably 5 to 40 mg, yet more preferably 10 to 30 mg of lovastatin. Alternatively, when the composition is administered with the second composition comprising lovastatin, or a pharmaceutically acceptable salt thereof, as described above, each dose comprises 0.5 to 50 mg, preferably 2.5 to 45 mg, more preferably 5 to 40 mg, yet more preferably 10 to 30 mg of lovastatin. Each dose or composition may be administered separately or sequentially i.e. at about the same time, and preferably within about 1 hour of each other.
In an embodiment of the invention, the composition is administered three times daily. Preferably each dose is 0.6 mg to 15 mg, more preferably 1.3 mg to 6.5 mg, yet more preferably 5 mg to 6.5 mg of trifluoperazine. Exemplary doses are 1, 3, or 5 mg of trifluoperazine. When the composition further comprises lovastatin, or a pharmaceutically acceptable salt thereof, as described above, each dose comprises 0.3 mg to 33 mg, more preferably 1.5 mg to 30 mg, more preferably 3 mg to 30 mg, yet more preferably 6 mg to 20 mg of lovastatin. Alternatively, when the composition is administered with the second composition comprising lovastatin, or a pharmaceutically acceptable salt thereof, as described above, each dose comprises 0.3 mg to 33 mg, more preferably 1.5 mg to 30 mg, more preferably 3 mg to 30 mg, yet more preferably 6 to 20 mg of lovastatin. Each dose or composition may be administered separately or sequentially i.e. at about the same time, and preferably within about 1 hour of each other.
Preferably, the dosage regime is such that the total daily dosage of trifluoperazine does not exceed 40 mg.
Suitably the effective dose of trifluoperazine results in a concentration of 1 to 10 pM, preferably 1 to 5 pM, more preferably 1 to 4 pM in cells.
In order to treat neuroblastoma, the composition comprising trifluoperazine is used in a chronic dosage regime i.e. chronic, long-term treatment. Suitably the regime lasts for at least one month, suitably at least two months, such as at least three months.
The present invention also relates to a kit comprising: (i) at least one dose of trifluoperazine, or a pharmaceutically acceptable salt thereof; and optionally (ii) at least one dose of lovastatin, or a pharmaceutically acceptable salt thereof, for simultaneous, separate or sequential use in the treatment of neuroblastoma.
The present invention also relates to the use of a composition comprising trifluoperazine, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for use in the treatment of neuroblastoma. This embodiment of the invention may have any of the preferred features described above.
The present invention also relates to a method of treating -neuroblastoma comprising administering the patient with a composition comprising trifluoperazine or a pharmaceutically acceptable salt thereof.
This embodiment of the invention may have any of the preferred features described above. The method of administration may be according to any of the routes described above.
The present invention further relates to a method of treating -neuroblastoma comprising administering the patient with a composition comprising trifluoperazine or a pharmaceutically acceptable salt thereof, and a second composition comprising lovastatin, or a pharmaceutically acceptable salt thereof, wherein the two compositions are administered to the patient simultaneously, separately or sequentially.
This embodiment of the invention may have any of the preferred features described above. The method of administration may be according to any of the routes described above.
For the avoidance of doubt, the present invention also embraces prodrugs which react in vivo to give a compound of the present invention. Experimental Section
Example 1: Monotherapy in vitro drug testing of trifluoperazine and lovastatin
The individual efficacies of trifluoperazine and lovastatin were investigated and their ability to inhibit cell growth utilizing neuroblastoma patient-derived xenograft tumours (PDX1, PDX2 and PDX3).
Methods
All in vitro preclinical models were derived from patient derived xenograft tumours and cultured ex vivo. The establishment of PDX 1, 2 &. 3 was described in Braekeveldt et al, Int. J. Cancer, 2015, E252-E261. All models had MYCN amplification and are therefore representative of high-risk patients.
PDX 1, 2 &. 3 tumours were grown in male or female NSG mice, mice were housed under pathogen free conditions and given access to food and water ab libitum. Animals were sacrificed, tumour tissues excised and digested for 45 mins at 37°C with Liberase (0.15mg/ml). Dissociated tissue was passed through a 70pm cell strainer and cultured in non-adherent plates as tumour spheroids at 37°C in a humidified atmosphere with 5% CO2 in the following culture medium: Dulbecco's Modified Eagle's medium DMEM/F12 medium with glutamine, 100 IU/ml penicillin and 100 pg/ml of streptomycin, 2% B27 supplement, 40 ng/ml of basic fibroblast growth factor (FGF) 2 and 20 ng/ml of epidermal growth factor (EGF). Directly upon seeding cells were treated with the compounds solubilised in DMSO, then cultured for 3 or 7 days. Cell viability was quantified using the CellTiter-Glo® luminescence Cell Viability Assay. Using this assay the number of metabolically active viable cells present in a culture can be determined based on the concentration of ATP. The luminescent signal produced is proportional to the amount of ATP present.
Lovastatin and trifluoperazine hydrochloride had a purity of >95%. Drugs were tested in triplicate, at a minimum of 6 concentrations, top concentration of IOmM (free- base equivalent). Cell viability readouts were normalized to DMSO treated controls, concentration-response curves were plotted and IC50 and R2 values were calculated using GraphPad Prism 8.4.3. Results
Reduction in cell viability bv trifluoperazine
Results for trifluoperazine treatment in neuroblastoma cell lines can be seen in Figures 1A-F. Trifluoperazine inhibited the growth of PDX 1, 2 and 3 after 3 and 7 days in culture. Trifluoperazine inhibited cell viability by 50% in all cell models at both timepoints at concentrations of 4pM or less.
Reduction in cell viability bv lovastatin
Results for lovastatin treatment in neuroblastoma cell lines can be seen in Figures 2A-F. Lovastatin inhibited the growth of PDX 1, 2 81 3 after 3 days in culture. After 7 days of culture lovastatin inhibited the viability of all three cell lines at an IC50 of 0.84pM (PDX 1), 2.67pM (PDX 2) and 0.15pM (PDX3).
Example 2 - Fixed Concentration Combination Study of trifluoperazine and lovastatin
Materials and Methods Cell culture conditions
Fixed concentration combination studies were carried out using PDX 1 &. 2 cell models. Cells were cultured using the same protocol as described for the monotherapy studies. Cells were treated for 7 days with lovastatin and trifluoperazine at a fixed concentration indicated in Table 1.
The fixed concentrations were equivalent to the IC50 values of each agent at 7 days as monotherapies in the two models.
Table 1 - Concentrations of trifluoperazine and lovastatin and used in the combination study
Figure imgf000013_0001
Trypan blue staining assay
Viable cells in the culture were quantified using the trypan blue staining assay. Trypan blue is an azo dye that is cell membrane impermeable that can only enter dead cells that have a permeable membrane. The dye binds to intracellular proteins and therefore dead cells are stained blue. The number of live (unstained) and dead (stained) cells were then quantified, and the percentage of viable cells calculated.
Flow cytometry
Cell death was quantified by Annexin V/Propidium iodide (PI) and caspase 3 staining using flow cytometry. For Annexin V/PI staining cells were incubated with fluorescent annexin V and PI, a human vascular anti-coagulant that binds to phospholipid phosphatidylserine (PS). PS is normally found on the inner leaflets of the plasma membrane, during apoptosis these move to the outer leaflet of the plasma membrane. Therefore, annexin V only binds to apoptotic cells. PI is a red fluorescent stain that binds to DNA and is impermeable to live cells, therefore only binds to dead cells. Annexin V/PI assay was carried out according to manufacturer's instructions. Caspase 3 an apoptosis marker was quantified using the NucView® Caspase-3 assay kit in live cells according to manufacturer's instructions. Cells were counted on a FACSverse flow cytometer and populations gated and quantified.
Data Analysis
Graphs of live and dead cell values were plotted using GraphPad Prism 8.4.2.
Results
Trifluoperazine and lovastatin
The results can be seen in Figures 3A-C. A reduction in cell viability and increase in cell death (annexin V/PI) was observed in both PDX 1 and PDX 2 cells treated with lovastatin and trifluoperazine as single agents. When the agents were combined there was a further reduction in cell viability with no viable cells being present in PDX 2 cell cultures. In line with this reduction in cell viability, there was a large increase in cell death in the combination treated cell cultures quantified by annexin V/PI staining. The cell death induced by the combination was via the apoptotic pathway, as indicated by an increase in caspase 3 positive cells. The results for the combination of lovastatin and trifluoperazine were greater than an expected additive effect based on the single agent results, demonstrating a synergistic benefit to their combination. Example 3 - Concentration Response Combination Studies of lovastatin and trifluoperazine
Materials and Methods Cell culture conditions
Concentration response combination studies were carried out in the PDX 1, 2 and 3 cell models. Cells were cultured using the same protocol as described for the monotherapy studies. At seeding, cells were treated with lovastatin combined with trifluoperazine in a 6x6 concentration matrix of increasing concentrations of both drugs. Cells were cultured for 3 or 7 days; cell viability was quantified using the CellTiter-Glo® luminescence Cell Viability Assay.
Drugs
Lovastatin and trifluoperazine hydrochloride had a purity of >95%. Drugs were tested in triplicate, the top concentration of lovastatin was 20pM, top concentration of trifluoperazine was 5pM (free-base equivalent).
Data analysis
Cell viability readouts were normalized to DMSO treated controls and a viability matrix was produced. ZIP combination synergy scores were calculated from this matrix using ZIP Synergy Finder ver 2.0 https ://svneravfinder. fimm.fi/ (Ianevski et al, Nucleic Acids Research, 2020, Pages W488-W493). Scores of -10 to 10 indicate an additive combination effect, scores of >10 indicate a synergistic combination effect. Results
The results of the combined treatment of trifluoperazine and lovastatin can be seen in Table 2. There was a synergistic reduction in cell viability of both PDX 1 and PDX 2 when lovastatin was combined with trifluoperazine indicated by ZIP scores of >10.
Table 2 - ZIP Synergy scores for combinations of trifluoperazine and lovastatin (Scores of -10 to 10 indicate an additive combination effect, scores of > 10 indicate a synergistic combination effect)
Figure imgf000015_0001
Figure imgf000016_0001
Conclusions
Trifluoperazine inhibits the cell viability and increases cell death in neuroblastoma cell lines, and is therefore effective at treating neuroblastoma. The reduction in cell viability can be further enhanced when a combination of trifluoperazine and lovastatin is used. The combination treatment leads to synergistic increases (i.e. greater than the expected additive values) in cell death and reduction in cell viability, and this synergy is quantified by the ZIP synergy scores.

Claims

Claims
1. A composition comprising trifluoperazine or a pharmaceutically acceptable salt thereof, for use in the treatment of neuroblastoma.
2. The composition for use according to any preceding claim wherein the subject of the treatment is a moderate or high risk subject, preferably high risk.
3. The composition for use according to any preceding claim, wherein the subject of the treatment is a human.
4. The composition for use according to any preceding claim, wherein the subject of the treatment is a paediatric patient.
5. The composition for use according to any preceding claim, wherein the pharmaceutically acceptable salt of trifluoperazine is hydrochloride.
6. The composition for use according to any preceding claim, wherein the composition comprises 2 mg to 40 mg, preferably 4 mg to 20 mg, more preferably 15 to 20 mg of trifluoperazine.
7. The composition for use according to any preceding claim, wherein administration is by a dose two times per day.
8. The composition for use according to claim 7, wherein the dose comprises 1 mg to 20 mg, preferably 2 mg to 10 mg, more preferably 7.5 mg to 10 mg of trifluoperazine.
9. The composition for use according to any of claims 1 to 5, where administration is by a dose three times per day.
10. The composition for use according to claim 9, wherein the dose comprises 0.6 mg to 15 mg, preferably 1.3 mg to 6.5 mg, more preferably 5 mg to 6.5 mg of trifluoperazine.
11. The composition for use according to any preceding claim, to be administered orally or intravenously.
12. The composition for use according to any of claims 1 to 10, to be administered by parenteral, transdermal, sublingual, rectal or inhaled administration.
13. The composition for use according to any preceding claim, wherein trifluoperazine is the only active agent in the composition.
14. The composition for use according to any of claims 1 to 12 wherein the composition further comprises lovastatin, or a pharmaceutically acceptable salt thereof.
15. The composition for use according to any of claims 1 to 12 in combination with a second composition comprising lovastatin, or a pharmaceutically acceptable salt thereof, wherein the two compositions are to be administered to a subject simultaneously, separately or sequentially.
16. The composition for use according to claims 14 or 15, wherein the amount of lovastatin is 1 to 100 mg.
17. A kit comprising :
(i) at least one dose of trifluoperazine, or a pharmaceutically acceptable salt thereof; and
(ii) at least one dose of lovastatin, or a pharmaceutically acceptable salt thereof, for simultaneous, separate or sequential use in the treatment of neuroblastoma.
18. A kit according to claim 17, having any of the additional features of claims 2 to 16.
19. Use of trifluoperazine, or a pharmaceutically acceptable salt thereof, for the manufacture of a medicament for use in the treatment of neuroblastoma.
20. Use according to claim 19, having any of the additional features of claims 2 to 16.
21. A method of treating neuroblastoma comprising administering the patient a composition comprising trifluoperazine or a pharmaceutically acceptable salt thereof.
22. The method according to claim 21, having any of the additional features of claims 2 to 16.
23. The method according to claims 21 or 22 wherein the method further comprises administering to the patient a second composition comprising lovastatin, or a pharmaceutically acceptable salt thereof, wherein the two compositions are administered simultaneously, separately or sequentially.
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Non-Patent Citations (7)

* Cited by examiner, † Cited by third party
Title
BIEDLER J L ET AL: "Collateral sensitivity of multidrug-resistant human neuroblastoma cells to chemo sensitizers verapamil and trifluoperazine", AMERICAN ASSOCIATION FOR CANCER RESEARCH. PROCEEDINGS OF THE ANNUAL MEETING; 84TH ANNUAL MEETING OF THE AMERICAN ASSOCIATION FOR CANCER RESEARCH; ORLANDO, FLORIDA, USA; MAY 19-22, 1993, AMERICAN ASSOCIATION FOR CANCER RESEARCH, US, vol. 34, 1 January 1993 (1993-01-01), pages 322, XP009535128, ISSN: 0197-016X *
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