WO2022259157A1

WO2022259157A1 - A triple pharmaceutical combination comprising dabrafenib, trametinib and a shp2 inhibitor

Info

Publication number: WO2022259157A1
Application number: PCT/IB2022/055309
Authority: WO
Inventors: Giordano Caponigro; Vesselina COOKE; David KODACK; Alice LOO; Morvarid MOHSENI
Original assignee: Novartis Ag
Priority date: 2021-06-09
Filing date: 2022-06-07
Publication date: 2022-12-15
Also published as: TW202313041A

Abstract

The present invention relates to a pharmaceutical combination comprising dabrafenib, trametinib and a SHP2 inhibitor; pharmaceutical compositions comprising the same; and methods of using such combinations and compositions in the treatment or prevention of conditions in which MAPK pathway inhibition is beneficial, for example, in the treatment of cancers.

Description

A TRIPLE PHARMACEUTICAL COMBINATION COMPRISING

DABRAFENIB, TRAMETINIB AND A SHP2 INHIBITOR.

FIELD OF THE INVENTION [0001] The present invention relates to a pharmaceutical combination comprising dabrafenib, or a pharmaceutically acceptable salt thereof, trametinib, or a pharmaceutically acceptable salt thereof, and a SHP2 inhibitor (SHP2i) such as (3S,4S)-8-(6-amino-5-((2- amino-3 -chloropyridin-4-yl)thio)pyrazin-2-yl)-3 -methyl-2-oxa-8-azaspiro [4.5] decan-4-amine (“Compound A”) or a pharmaceutically acceptable salt thereof; pharmaceutical compositions comprising the same; commercial packages comprising the same; and methods of using such combinations and compositions in the treatment or prevention of conditions in which MAPK pathway inhibition is beneficial, for example, in the treatment of cancers. The present invention also povides such combinations for use in the treatments of such conditions or cancers, including colorectal cancer (CRC) such as BRAF gain of function colorectal cancer.

BACKGROUND OF THE INVENTION

[0002] The MAPK pathway is a key signaling cascade that drives cell proliferation, differentiation, and survival. Dysregulation of this pathway underlies many instances of tumorigenesis. Aberrant signaling or inappropriate activation of the MAPK pathway has been shown in multiple tumor types and can occur through several distinct mechanisms, including activating mutations in RAS and BRAF. The MAPK pathway is frequently mutated in human cancer with KRAS and BRAl·^' mutations being among the most frequent (approximately 30%). RAS mutations, particularly gain of function mutations, have been detected in 9-30% of all cancers, with KRAS mutations having the highest prevalence (86%). [0003] The extracellular signal-regulated kinases (ERKs) are one class of signaling kinases that are involved in conveying extracellular signals into cells and subcellular organelles. ERK1 and ERK2 are involved in regulating a wide range of activities and dysregulation of the ERK1/2 cascade is known to cause a variety of pathologies including neurodegenerative diseases, developmental diseases, diabetes and cancer. The role of ERK1/2 in cancer is of special interest because activating mutations upstream of ERK1/2 in its signaling cascade are believed to be responsible for more than half of all cancers. Moreover, excessive ERK1/2 activity was also found in cancers where the upstream components were not mutated, suggesting that ERK1/2 signaling plays a role in carcinogenesis even in cancers without mutational activations. The ERK pathway has also been shown to control tumor cell migration and invasion, and thus may be associated with metastasis.

[0004] The prognosis for patients suffering from certain cancers remains poor.

Resistance to treatment occurs frequently and not all patients respond to available treatments. For example, the median survival for patients suffering from advanced colorectal cancer with BRAF mutation is less than 12 months. It is thus important to develop new therapies for patients suffering from cancer to achieve better clinical outcomes. Treatment options which are better tolerated and/or provide durable anti-tumor responses are also desired.

SUMMARY OF THE INVENTION

[0005] The triple combination of the present invention provides for a RAF inhibitor, a

MEK inhibitor and a SHP2 inhibitor. In one aspect, the triple combination: dabrafenib; trametinib; and a SHP2 inhibitor such as (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4- yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine (compound A); can be used as therapies for the treatment of diseases or disorders resulting from the aberrant activity of the MAPK pathway including, but not limited to, breast cancer, cholangiocarcinoma, salivary gland cancer, colorectal cancer, melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer. Triple combinations of dabrafenib, trametinib, and compound A, are particularly useful in the treatment of colorectal cancer (CRC), including advanced or metastatic colorectal cancer, which is BRAF gain of function or BRAFV600E mutant.

[0006] The present invention provides a pharmaceutical combination comprising:

(a) N-(3-(5-(2-aminopyrimidin-4-yl)-2-(tert-butyl)thiazol-4-yl)-2-fluorophenyl)-2,6- difluorobenzenesulfonamide (dabrafenib), or a pharmaceutically acceptable salt thereof, having the structure:

(b) N-(3-(3-cyclopropyl-5-((2-fluoro-4-iodophenyl)amino)-6,8-dimethyl-2,4,7-trioxo-3,4,6,7- tetrahydropyrido[4,3-d]pyrimidin-l(2H)-yl)phenyl)acetamide (trametinib), or a pharmaceutically acceptable salt or solvate thereof, having the structure:

(c) a SHP2 inhibitor such as (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4- yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine (Compound A), or a pharmaceutically acceptable salt thereof, having the structure:

[0007] Pharmaceutical combinations of dabrafenib, or a pharmaceutically acceptable salt thereof, trametinib, or a pharmaceutically acceptable salt thereof, and a SHP2 inhibitor such as Compound A, or a pharmaceutically acceptable salt thereof, will also be referred to herein as a “combination of the invention”.

[0008] There is provided a combination of the invention for use in the treatment of cancer, e.g for use in a cancer which is selected from breast cancer, cholangiocarcinoma, salivary gland cancer, colorectal cancer, melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer.

[0009] There is provided a pharmaceutical combination of dabrafenib, or a pharmaceutically acceptable salt thereof, trametinib, or a pharmaceutically acceptable salt thereof, and a SHP2 inhibitor such as Compound A, or a pharmaceutically acceptable salt thereof, for example, for use in a cancer which is selected from breast cancer, cholangiocarcinoma, salivary gland cancer, colorectal cancer, melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer.

[0010] There is also provided a combination of dabrafenib, or a pharmaceutically acceptable salt thereof, trametinib, or a pharmaceutically acceptable salt thereof, and a SHP2 inhibitor such as Compound A, or a pharmaceutically acceptable salt thereof, for use in the treatment of colorectal cancer (which includes advanced or metastsatic colorectal cancer) which is BRAF gain of function or BRAFV600E, V600D or V600K mutant.

[0011] Also provided herein is a combination of the invention for use in the treatment of colorectal cancer (which includes advanced or metastsatic colorectal cancer) which is BRAF gain of function or BRAFV600E mutant.

[0012] In another embodiment of the combination of the invention, dabrafenib, or a pharmaceutically acceptable salt thereof, trametinib, or a pharmaceutically acceptable salt thereof, and a SHP2 inhibitor such as Compound A, or a pharmaceutically acceptable salt thereof, and are in the same formulation.

[0013] In another embodiment of the combination of the invention, dabrafenib, or a pharmaceutically acceptable salt thereof, trametinib, or a pharmaceutically acceptable salt thereof, and a SHP2 inhibitor such as Compound A, or a pharmaceutically acceptable salt thereof, are in separate formulations. [0014] In another embodiment, the combination of the invention is for simultaneous or sequential (in any order) administration.

[0015] In another embodiment, the present invention provides a method for treating cancer in a subject in need thereof comprising administering to the subject a therapeutically effective amount of the combination of the invention. [0016] In a further embodiment of the method, the cancer is selected from breast cancer, cholangiocarcinoma, salivary gland cancer, colorectal cancer, melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer.

[0017] In a further embodiment, the present invention provides a combination of the invention for use in the manufacture of a medicament for treating a cancer selected from breast cancer, cholangiocarcinoma, salivary gland cancer, colorectal cancer, melanoma, non small cell lung cancer, ovarian cancer and thyroid cancer.

[0018] In another embodiment there is provided a pharmaceutical composition or commercial package (for example, a kit-of-parts) comprising the combination of the invention.

[0019] In a further embodiment, the pharmaceutical composition further comprises one or more pharmaceutically acceptable excipients.

BRIEF DESCRIPTION OF THE DRAWINGS

[0020] Fig. 1 shows the best average response of 17 CRC PDX models to dabrafenib + trametinib + TN0155 (compound A) treatment in MCT2019.

[0021] Fig. 2 shows a Kaplan-Meier plot of tumor doubling of CRC PDX models in

MCT2019 during treatment of dabrafenib + trametinib + TN0155 (compound A) combination, compared with dabrafenib + trametinib and dabrafenib + trametinib + cetuximab treatments. [0022] Fig. 3 shows body weight changes of PDX-bearing mice during treatment with dabrafenib + trametinib + TN0155 (compound A) combination, compared with dabrafenib + trametinib or dabfarfenib + trametinib + cetuximab treatments.

DESCRIPTION

[0023] The general terms used hereinbefore and hereinafter preferably have within the context of this disclosure the following meanings, unless otherwise indicated, where more general terms whereever used may, independently of each other, be replaced by more specific definitions or remain, thus defining more detailed embodiments of the invention:

[0024] “Dabrafenib” is N-(3-(5-(2-aminopyrimidin-4-yl)-2-(tert-butyl)thiazol-4-yl)-2- fluorophenyl)-2,6-difluorobenzenesulfonamide, a selective inhibitor of mutated BRAF at V600 capable of inhibiting BRAF(V600E), BRAF(V600K) and BRAF(V600G) mutations, (also known as: N- { 3 -[5 -(2-Amino-4-pyrimidinyl)-2-( 1 , 1 -dimethylethyl)- 1 ,3 -thiazol-4-yl] -2- fluorophenyl}-2,6-difluorobenzenesulfonamide; Tafmlar^®; & N-{3[5-(2-Amino-4- pyrimidinyl)-2-( 1 , 1 -dimethylethyl)- 1 ,3 -thiazol-4-yl] -2 -fluorophenyl } -2,6 difluorobenzene sulfonamide, methanesulfonate salt).

[0025] “Cetuximab” is an epidermal growth factor receptor (EGFR) inhibitor used for the treatment of metastatic colorectal cancer, metastatic non-small cell lung cancer and head and neck cancer. Cetuximab is an epidermal growth factor receptor-targetedlgGl monoclonal antibody that is approved for use in combination with irinotecan or as monotherapy in the treatment of metastatic CRC. Cetuximab is a chimeric (mouse/human) monoclonal antibody given by intravenous infusion.

[0026] “Trametinib” is N-(3-(3-cyclopropyl-5-((2-fluoro-4-iodophenyl)amino)-6,8- dimethyl-2,4,7-trioxo-3,4,6,7-tetrahydropyrido[4,3-d]pyrimidin-l(2H)-yl)phenyl)acetamide, a MEK inhibitor (also known as: N-{3-[3-cyclopropyl-5-(2-fluoro-4-iodo-phenylamino)6,8- dimethyl-2, 4, 7-trioxo-3, 4, 6, 7-tetrahydro-2H-pyrido[4,3-d]pyrimidin-l-yl]phenyl} acetamide dimethyl sulfoxide solvate; Mekinist^®).

[0027] “Compound A” is an inhibitor of SHP2. Compound A is (3S,4S)-8-(6-amino-

5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4- amine. A particularly preferred salt of Compound A is the succinate salt. [0028] SHP2 inhibitors include compound A (above) and compounds described in

WO2015/107493, WO2015/107494, WO2015/107495, WO2016/203406, W02016/203404, W02016/203405, WO2017/216706, WO2017/156397, W02020/063760, WO2018/172984, W02017/211303, W021/061706, WO2019/183367, WO2019/183364, WO2019/165073,

WO2019/067843, WO2018/218133, WO2018/081091, WO2018/057884, WO2020/247643, W02020/076723, WO2019/199792, WO2019/118909, WO2019/075265, W02019/051084,

WO2018/136265, WO2018/136264, WO2018/013597, W02020/033828, WO2019/213318, W02019/158019, WO2021/088945, W02020/081848, WO21/018287, W02020/094018, WO2021/033153, W02020/022323, WO2020/177653, WO2021/073439, W02020/156243, WO2020/156242, W02020/249079, W02020/033286, W02021/061515, WO2019/182960, W02020/094104, W02020/210384, WO2020/181283, W02021/043077, WO2021/028362,

WO2020/259679, W02020/108590 & WO2019/051469. [0029] The term “subject” or “patient” as used herein is intended to include animals, which are capable of suffering from or afflicted with a cancer or any disorder involving, directly or indirectly, a cancer. Examples of subjects include mammals, e.g., humans, apes, monkeys, dogs, cows, horses, pigs, sheep, goats, cats, mice, rabbits, rats, and transgenic non- human animals. In an embodiment, the subject is a human, e.g., a human suffering from, at risk of suffering from, or potentially capable of suffering from cancers.

[0030] The term “treating” or “treatment” as used herein comprises a treatment relieving, reducing or alleviating at least one symptom in a subject or effecting a delay of progression of a disease. For example, treatment can be the diminishment of one or several symptoms of a disorder or complete eradication of a disorder, such as cancer. Within the meaning of the present disclosure, the term “treat” also denotes to arrest, delay the onset (i.e., the period prior to clinical manifestation of a disease) and/or reduce the risk of developing or worsening a disease.

[0031] The terms “comprising” and “including” are used herein in their open-ended and non-limiting sense unless otherwise noted.

[0032] The terms “a” and “an” and “the” and similar references in the context of describing the invention (especially in the context of the following claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. Where the plural form is used for compounds, salts, and the like, this is taken to mean also a single compound, salt, or the like.

[0033] By “a combination” or “in combination with” or “co-administration with” and such like, it is not intended to imply that the therapy or the therapeutic agents must be physically mixed or administered at the same time and/or formulated for delivery together, although these methods of delivery are within the scope described herein. A therapeutic agent in these combinations can be administered concurrently with, prior to, or subsequent to, one or more other additional therapies or therapeutic agents. The therapeutic agents or therapeutic protocol can be administered in any order. In general, each agent will be administered at a dose and/or on a time schedule determined for that agent. It will further be appreciated that the additional therapeutic agent utilized in this combination may be administered together in a single composition or administered separately in different compositions. In general, it is expected that additional therapeutic agents utilized in combination be utilized at levels that do not exceed the levels at which they are utilized individually. In some embodiments, the levels utilized in combination will be lower than those utilized as single-agent therapeutics. [0034] When describing a dosage or dose herein as ‘about’ a specified amount, the actual dosage or dose can vary by up to 10%, e.g. 5%, from the stated amount: this usage of ‘about’ recognizes that the precise amount in a given dose or dosage form may differ slightly from an intended amount for various reasons without materially affecting the in vivo effect of the administered compound. The skilled person will understand that where a dose or dosage of a therapeutic compound is quoted herein, that amount refers to the amount of the therapeutic compound in its free form or unsolvated form.

[0035] The phrase "therapeutically-effective amount" as used herein means an amount of a compound, material, or composition comprising a compound of the present invention which is effective for producing some desired therapeutic effect in at least a sub-population of cells in an animal (including a human) at a reasonable benefit/risk ratio applicable to any medical treatment.

[0036] The phrase "pharmaceutically acceptable" is employed herein to refer to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio.

[0037] The combinations of the invention, dabrafenib, trametinib and compound A, is also intended to represent unlabeled forms as well as isotopically labeled forms of the compounds. Isotopically labeled compounds have one or more atoms replaced by an atom having a selected atomic mass or mass number. Examples of isotopes that can be incorporated into dabrafenib, trametinib and Compound A include isotopes of hydrogen, carbon, nitrogen, oxygen, phosphorous, fluorine, and chlorine, such as ²H, ³H, ⁿC, ¹³C, ¹⁴C, ¹⁵N, ¹⁸F ³¹P, ³²P, ³⁵S, ³⁶C1, ¹²³I, ¹²⁴I, ¹²⁵I respectively. The invention includes isotopically labeled dabrafenib, trametinib and compound A, for example into which radioactive isotopes, such as ³H and ¹⁴C, or non-radioactive isotopes, such as ²H and ¹³C, are present. Isotopically labelled dabrafenib, trametinib and compound A are useful in metabolic studies (with ¹⁴C), reaction kinetic studies (with, for example ²H or ³H), detection or imaging techniques, such as positron emission tomography (PET) or single-photon emission computed tomography (SPECT) including drug or substrate tissue distribution assays, or in radioactive treatment of patients. In particular, dabrafenib, trametinib or compound A labeled with ¹⁸F may be particularly desirable for PET or SPECT studies. Isotopically -labeled compounds of the invention can generally be prepared by conventional techniques known to those skilled in the art or by processes analogous to those described in the accompanying Examples using appropriate isotopically-labeled reagents.

[0038] Further, substitution with heavier isotopes, particularly deuterium (i.e., ²H or D) may afford certain therapeutic advantages resulting from greater metabolic stability, for example increased in vivo half-life or reduced dosage requirements or an improvement in therapeutic index. It is understood that deuterium in this context is regarded as a substituent of either dabrafenib, trametinib or compound A. The concentration of such a heavier isotope, specifically deuterium, may be defined by the isotopic enrichment factor. The term "isotopic enrichment factor" as used herein means the ratio between the isotopic abundance and the natural abundance of a specified isotope. If a substituent dabrafenib, trametinib or compound A is denoted deuterium, such compound has an isotopic enrichment factor for each designated deuterium atom of at least 3500 (52.5% deuterium incorporation at each designated deuterium atom), at least 4000 (60% deuterium incorporation), at least 4500 (67.5% deuterium incorporation), at least 5000 (75% deuterium incorporation), at least 5500 (82.5% deuterium incorporation), at least 6000 (90% deuterium incorporation), at least 6333.3 (95% deuterium incorporation), at least 6466.7 (97% deuterium incorporation), at least 6600 (99% deuterium incorporation), or at least 6633.3 (99.5% deuterium incorporation). Description of Preferred Embodiments

[0039] Dabrafenib is an orally bioavailable small molecule with RAF inhibitory activity. Trametinib is an orally bioavailable small molecule with MEK inhibitory activity. Compound A is an orally bioavailable small molecule with SHP2 inhibitory activity.

[0040] In one embodiment, with respect to the pharmaceutical combination of the invention, is a pharmaceutical combination comprising: N-(3-(5-(2-aminopyrimidin-4-yl)-2- (tert-butyl)thiazol-4-yl)-2-fluorophenyl)-2,6-difluorobenzenesulfonamide (dabrafenib), or a pharmaceutically acceptable salt thereof; N-(3-(3-cyclopropyl-5-((2-fluoro-4- iodophenyl)amino)-6,8-dimethyl-2,4,7-trioxo-3,4,6,7-tetrahydropyrido[4,3-d]pyrimidin- l(2H)-yl)phenyl)acetamide (trametinib), or a pharmaceutically acceptable salt thereof; and (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8- azaspiro[4.5]decan-4-amine (compound A), or a pharmaceutically acceptable salt thereof. [0041] In a further embodiment, N-(3-(5-(2-aminopyrimidin-4-yl)-2-(tert- butyl)thiazol-4-yl)-2-fluorophenyl)-2,6-difluorobenzenesulfonamide (dabrafenib), or a pharmaceutically acceptable salt thereof, N-(3-(3-cyclopropyl-5-((2-fluoro-4- iodophenyl)amino)-6,8-dimethyl-2,4,7-trioxo-3,4,6,7-tetrahydropyrido[4,3-d]pyrimidin- l(2H)-yl)phenyl)acetamide (trametinib), or a pharmaceutically acceptable salt thereof, and (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8- azaspiro[4.5]decan-4-amine (compound A), or a pharmaceutically acceptable salt thereof, are administered separately, simultaneously or sequentially, in any order. [0042] In a further embodiment, the pharmaceutical combination is for oral administration.

[0043] In a further embodiment of the pharmaceutical combination, N-(3-(5-(2- aminopyrimidin-4-yl)-2-(tert-butyl)thiazol-4-yl)-2-fluorophenyl)-2,6- difluorobenzenesulfonamide (dabrafenib) is in an oral dosage form. [0044] In a further embodiment of the pharmaceutical combination, N-(3-(3- cyclopropyl-5-((2-fluoro-4-iodophenyl)amino)-6,8-dimethyl-2,4,7-trioxo-3,4,6,7- tetrahydropyrido[4,3-d]pyrimidin-l(2H)-yl)phenyl)acetamide (trametinib) is in an oral dosage form.

[0045] In a further embodiment of the pharmaceutical combination, (3S,4S)-8-(6- amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8- azaspiro[4.5]decan-4-amine (compound A) is in an oral dosage form.

[0046] In another embodiment is a pharmaceutical composition or a commercial package comprising the pharmaceutical combination (as described in any of the embodiments above) and at least one pharmaceutically acceptable carrier. [0047] In another embodiment is a pharmaceutical combination (as described in any of the embodiments above) or the pharmaceutical composition or the commercial package (as described in the embodiments above) for use in the treatment of cancer.

[0048] In a further embodiment, the cancer is selected from breast cancer, cholangiocarcinoma, colorectal cancer (CRC), melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer.

[0049] In a further embodiment, the cancer is advanced or metastatic colorectal cancer.

[0050] In a further embodiment, the cancer is BRAF gain of function CRC or BRAF V600E, V600D or V600K CRC.

[0051] In another embodiment is a use of the pharmaceutical combination according to any of the above embodiments or the pharmaceutical composition or commercial package according to the above embodiments for the manufacture of a medicament for the treatment of cancer. [0052] In a further embodiment, the cancer is selected from breast cancer, cholangiocarcinoma, colorectal cancer, melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer, optionally wherein the cancer is advanced or metastatic colorectal cancer, optionally wherein the cancer is BRAF gain of function CRC or BRAF V600E, V600D or V600K CRC. [0053] In another embodiment is a method of treating a cancer selected from breast cancer, cholangiocarcinoma, colorectal cancer, melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer comprising administrating to a patient in need thereof a pharmaceutical combination or commercial package according to any one of the above embodiemnts or the pharmaceutical composition according to the above embodiments. [0054] In a further embodiment, the colorectal cancer is advanced or metastatic colorectal cancer.

[0055] In a further embodiment, the colorectal cancer is BRAF gain of function CRC or BRAF V600E, V600D or V600K CRC.

[0056] In a further embodiment, N-(3-(5-(2-aminopyrimidin-4-yl)-2-(tert- butyl)thiazol-4-yl)-2-fluorophenyl)-2,6-difluorobenzenesulfonamide (dabrafenib) is administered orally at a dose of about from about 1 to about 150 mg per day (for example, 1, 2, 5, 10, 50, 100 or 150 mg per day).

[0057] In a further embodiment, N-(3-(3-cyclopropyl-5-((2-fluoro-4- iodophenyl)amino)-6,8-dimethyl-2,4,7-trioxo-3,4,6,7-tetrahydropyrido[4,3-d]pyrimidin- l(2H)-yl)phenyl)acetamide (trametinib) dimethyl sulfoxide per day is administered orally at a dose of about 0.5635, 1.127 or 2.254 mg per day. Thus, trametinib may be administered at a dose of from about 0.5 to about 2 mg per day, or at dose which is selected from about 0.5, 1 and 2 mg daily in any method or use of the invention.

[0058] In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4- yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine (compound A) is adminstered orally at a dose of from about 1.5 mg per day, or 3 mg per day, or 6 mg per day, or 10 mg per day, or 20 mg per day, or 30 mg per day, or 40 mg per day, or 50 mg per day, or 60 mg per day, or 70 mg per day, or 80 mg per day, or 90 mg per day, to about 100 mg per day.

[0059] In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4- yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine (compound A) is adminstered orally wherein the dose per day (BID or QD) is on a 21 day cycle of 2 weeks on drug followed by 1 week off drug.

[0060] In a further embodiment, (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4- yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine (compound A) is adminstered orally wherein the dose per day (BID or QD) is on a 14 day cycle of 2 weeks on drug followed by 1 week off drug.

Pharmacology and Utility

[0061] The RAS/RAF/MEK/ERK or mitogen activated protein kinase (MAPK) pathway is a key signaling cascade that integrates upstream cellular signals, such as from growth factor receptor tyrosine kinases, to orchestrate cell proliferation, differentiation, and survival. The

MAPK signaling pathway is frequently dysregulated in human cancers, most commonly through mutation of members of the RAS family of genes. These mutations promote the GTP-bound state resulting in RAS activity leading in turn to activation of RAF, MEK, and ERK proteins. RAS mutations are found in multiple cancer types, including colorectal, lung, and pancreatic cancers. [0062] RAF (Rapidly Accelerated Fibrosarcoma) is a serine-threonine protein kinase discovered as a retroviral oncogene. The RAF family of proteins (ARAF, BRAF, CRAF) signals just downstream of activated RAS. Activated GTP-bound RAS recruits cytosolic inactive RAF monomers to the plasma membrane where RAF binds to GTP-RAS thereby promoting homo- and heterodimerization of RAF. The dimerization of RAF facilitates conformational changes that lead to catalytically activated RAF. Activated RAF dimers phosphorylate and activate MEK1/2 (also known as mitogen-activated protein kinase) proteins, which subsequently phosphorylate and activate extracellular signal-regulated kinases (ERK1/2). ERKs phosphorylate a variety of substrates, including multiple transcription factors, thereby regulating several key cellular activities, including proliferation, metabolism, migration, and survival. The role of ERK1/2 in cancer is of special interest because activating mutations upstream of ERK1/2 in its signaling cascade are believed to be responsible for more than half of all cancers.

[0063] Dysregulated activation at any step in the MAPK pathway contributes to tumorigenesis. Activating BRAF mutations can be found in approximately 7% of cancers, with V600E accounting for greater than 90% of observed mutations in BRAF. The V600E mutation encodes a valine to glutamic acid substitution that exposes the active site of BRAF, enabling its constitutive activation as monomers or dimers independent of RAS. Inhibitors of active RAF, such as vemurafenib, dabrafenib, and encorafenib, have demonstrated dramatic activity in BRAF V600E metastatic melanoma with overall response rates (ORR) of 50-70%. The success of these inhibitors in V600E melanoma derives from the ability to bind to and inhibit the mutant monomeric form of RAF that is the oncogenic driver in cancer cells. However, in cancer cells that express wild-type BRAF, or in the normal cells of patients with V600E driven cancers, inhibitors such as vemurafenib paradoxically activate RAF signaling. The complexity of MAPK pathway signaling in the presence of monomeric RAF inhibitors is highlighted in patients whose BRAF V600E-dependent melanoma cells die while normal epidermal cells containing wild-type BRAF hyperproliferate. This paradoxical activation of RAF in wild-type cells is precipitated by the inhibitor’s binding to one protomer of a RAF dimer. This leads to a conformational change that prevents inhibitor binding to the second protomer, and transactivation of the second RAF protomer of the dimer ensues. Inhibition at sequential nodes of the MAPK pathway with RAF- and MEK-directed combination therapy attenuates RAF dimer signaling in normal cells, thereby improving safety and clinical activity in metastatic BRAF V600 melanoma. [0064] Single-agent RAF inhibitors or combination RAF/MEK inhibition in BRAF

V600E colorectal cancer (CRC) demonstrate minimal activity; clinical benefit is limited compared to the activity seen in melanoma. Intrinsic and acquired resistance to RAF inhibitors and MEK inhibitors develop at multiple levels of the MAPK pathway. The complexities of signaling feedback and alternate pathways that circumvent BRAF inhibition are central to the challenge of targeting activated BRAF in CRC. Under physiologic conditions, activated MAPK signaling through mutant BRAF leads to ERK-dependent negative feedback on signals generated through activated RAS. Intrinsic resistance to RAF inhibition manifests because drugs such as vemurafenib or dabrafenib effectively inhibit BRAF V600E signaling through MEK to ERK; however, this in turn releases ERK-dependent negative feedback into RAS signaling. Therefore, upstream signals are able to activate RAS, leading to the induction of BRAF V600E and wild-type homo- and heterodimers. Because agents such as dabrafenib and vemurafenib inhibit V600E activated monomers in BRAF -dependent CRC cells, RAS -stimulated RAF dimer signaling is unopposed, leading to ERK reactivation to a greater degree than is seen in BRAF V600E melanoma, and thus limiting the effectiveness of therapy in CRC.

[0065] Under the pressure of RAF and MEK inhibition in BRAF V600E CRC, acquired resistance quickly develops. For instance, in an analysis of nine tumor samples from eight patients experiencing disease progression after MAPK inhibition, genetic alterations leading to MAPK reactivation were uncovered. These included activating mutations in KRAS or NRAS, amplification of wild-type (WT) NRAS or KRAS or mutant BRAFN 600E, and an intragenic deletion in BRAF V600E. Acquired genetic alterations have also been reported, leading to reactivation of ERK signaling in the face of MAPK inhibitors. Acquired resistance may also arise through complementary signaling in the tumor microenvironment.

[0066] Though previous therapeutic approaches to BRA / -mutant CRC have focused on chemotherapy and/or targeted therapy, there is also a role for immunotherapy. During tumorigenesis, cancer cells exploit immune checkpoint pathways to avoid detection by the adaptive immune system. Monoclonal antibody (mAh) inhibitors of the Programmed Cell Death Protein- 1 (PD-1) and Programmed Death-Ligand 1 (PD-L1) immunological checkpoints have demonstrated significant antitumor activity in patients with various solid tumors. PD-1 is a particularly important immunological target, with inhibitors such as pembrolizumab and nivolumab demonstrating single-agent activity in melanoma, non-small cell lung carcinoma (NSCLC), and other solid tumors.

[0067] CRC, however, is generally unresponsive to PD-1 blockade with the exception of tumors possessing micro satellite instability. There is, however, rationale for the use of small molecule inhibitors to modulate the immune response. The same therapies that inhibit genetic dependencies on the MAPK pathway in cancer cells inhibit signaling cascades in immune cells. For instance, preclinical studies demonstrated that MAPK pathway inhibitors, such as BRAF and MEK inhibitors, could improve lymphocyte homing and function by increasing tumor infiltrating lymphocytes in tumors. [0068] Therefore, RAF and MEK inhibitors may modulate the immune response to tumors, and the combination of such agents with checkpoint blockade may increase the susceptibility of “immune cold” tumors such as CRC to PD-1 inhibition. Furthermore, approximately 20% of /i/M/'-mutant CRCs are characterized by genetic micro satellite instability (MSI-H: microsatellite instability-high). In MSI-H CRC, irrespective of BRAF genetic status, single-agent anti-PD-1 therapy has been associated with response rates of 30-50%.

[0069] Colorectal cancer (CRC) is a common disease with more than 1.8 million new cases estimated worldwide in 2018, along with >800,000 deaths (World Health Organization, Globocan 2018). Several critical genes and pathways important in the initiation and progression of CRC have been reported, including WNT, RAS-MAPK, PI3K, TGF-b, TP53 and DNA mismatch repair pathways. TCGA analysis provides further genetic details in receptor tyrosine kinase (RTK) signaling pathways, identifying up to 20% of CRC tumors containing upregulated IGF2, ERBB2, or ERBB3. In addition, downstream PI3K and MAPK signaling pathways are also frequently dysregulated, with >40% CRC tumors containing activating mutations in PIK3CA, KRAS or BRAF genes (TCGA Network, 2012). Activating mutations in the gene encoding BRAF V600E are present in approximately 10-15% of CRC patients, and mutated BRA / confers a poor prognosis. The V600E mutation occurs in approximately 90% of BRAF-raut t CRC, though V600D or V600K mutations are also found.

[0070] Effective treatment options for BRA / -mutant CRC are limited. Unlike melanoma, where single-agent BRAF inhibitors yielded responses rates of approximately 70% in the metastatic setting, single agent inhibition of metastatic BRA / -mutant CRC with vemurafenib was associated with an ORR of approximately 5% (Kopetz et al. 2015). Combination therapy with agents targeting the MAPK pathway have improved upon the effectiveness of BRAF inhibition, though outcomes are still poor. Dabrafenib combined with the MEK inhibitor trametinib was associated with an ORR of 12% and progression-free survival (PFS) of 3.5 months (Corcoran et al. 2015). Inhibitors of EGFR modestly improved upon the effectiveness of BRAF inhibition; BRAF inhibitors combined with EGFR inhibitors were associated with ORRs of 4-22% and PFS 3.2-4.2 months (Pan et al. 2018).

[0071] Src homology-2 domain containing protein tyrosine phosphatase-2 (SHP2, encoded by the PTPN11 gene) mediates cell signal transduction between multiple RTKs and their downstream pathways, and offers an important node of intervention to interrupt oncogenic signaling and inhibit tumor growth. TN0155 is a first-in-class allosteric inhibitor of wild-type SHP2. TN0155 binds the inactive, or “closed” conformation of SHP2, thereby preventing its opening into the active conformation. This prevents the transduction of signaling from activated RTKs to the downstream RAS/MAPK pathway.

[0072] Clinical studies in BRAF V600E CRC have demonstrated that the activity of RAF inhibitors alone or in combination with MEK ± EGFR inhibitors is limited by insufficient MAPK pathway suppression, and that in patients, mechanisms of resistance quickly arise even in the setting of initial clinical benefit. Acquired resistance mechanisms leading to MAPK pathway reactivation in patient tumors primarily involve activating genetic alterations in RAS, BRAF or MEK. [0073] Preclinical models of RAS, RAF, or MEK resistance mutations engineered into a

BRAF V600E cell line supported this concept. While the parental BRAF V600E cell line was sensitive to combinations of BRAF, MEK, EGFR, and/or ERK inhibitors, the introduction of KRAS, NRAS, MEK1, or MEK2 resistance mutations resulted in decreased sensitivity of engineered BRAF V600E cells to all inhibitor combinations, except for those containing an ERK inhibitor. Furthermore, the outgrowth of pre-existing, low-frequency pooled resistant clones in mouse xenografts was suppressed more effectively by treatment with drug combinations containing BRAF and ERK inhibitors, as compared to BRAF and MEK inhibitors.

[0074] The improved outcomes demonstrated by combined inhibition of RAF, MEK, and

EGFR signaling support the concept that inhibition of multiple nodes within the MAPK pathway is required for the treatment of BRAF V600 CRC. [0075] Nonetheless, intrinsic and acquired resistance to therapy remain important challenges, and clinical outcomes are still poor. There is a role for combination therapies that provide more robust suppression of MAPK signaling and address the complexity of mechanisms of resistance both within and beyond the MAPK pathway. Given the adaptive complexity of signal transduction that characterizes BRA / -mutant CRC, inhibition of proteins beyond RAF and ERK is required. As an illustration, one study of 218 BRAF-N 600E mutated CRC tumors identified distinct subsets of tumors characterized by high KRAS/mTOR/AKT/4EBPl EMT activation, while cell-cycle dysregulation characterized the other subset.

[0076] Despite the advances demonstrated by targeted therapy combinations, such as those studied in the BEACON trial (Kopetz et al. 2019), the ability to shut down the BRAF V600 oncogenic drive in cancer cells is limited by 1.) the inability to fully suppress RAF activity due the adaptive ability of RAF kinases to signal through ineffectively inhibited dimers, and 2.) ongoing ERK activation stimulated not only by adaptive mechanisms within the MAPK pathway, but also through parallel signaling pathways. Dabrafenib, vemurafenib, and encorafenib effectively suppress RAF activity in BRAF-vcmtwt cancer cells where monomeric V600E is an oncogenic driver. However, these drugs may also lead to the paradoxical activation of ERK through several mechanisms.

[0077] Combined inhibition of RAF and MEK improves upon pathway suppression; however, the persistence of ERK signaling underlies the limitations of this therapeutic approach. Blockade of ERK, the ultimate signal of the MAPK pathway, may circumvent adaptive upstream signals and provide for improved efficacy and resilience to acquired resistance.

[0078] SHP2 is a phosphatase that binds activated RTKs and transduces their signaling downstream to the RAS MAPK and PI3K/AKT pathways. Inhibition of SHP2 therefore inhibits RTK-mediated signaling. SHP2 is also known to regulate PI3K, Fak, RhoA, Ca2+ oscillations, Ca2+/Calcineurin and NFAT signaling, and SHP2 also acts downstream of cytokine signaling in the regulation of Jak/Stat signaling. In addition, SHP2 signals downstream of the immune checkpoint molecule PD-1, B- and T- lymphocyte attenuator (BTLA), and indoleamine 2,3- dioxygenase (IDO). Thus, SHP2 has RAS MAPK-independent functions in tumorigenesis by regulating neoplastic migration, invasion, metastasis, or anti-tumor immune response. [0079] Clinical studies adding anti-EGFR antibodies to RAF and MEK inhibition have demonstrated modestly improved outcomes in BRAF V600 CRC. Preclinical studies, however, suggest that other RTK pathways may contribute to signal activation in the setting of BRAF V600 CRC. SHP2 plays a central role in mediating signals emanating from not only EGFR, but also from other RTKs, and therefore has the potential to expand upon the activity of drugs such as cetuximab and panitumumab when combined with inhibitors of the MAPK pathway. Therefore, SHP2 inhibition can provide more effective initial MAPK pathway suppression and also better address mechanisms of MAPK pathway reactivation. The triple combination of dabrafenib + trametinib + Compound A (SHP2i) can inhibit the MAPK pathway in BRAF V600 colorectal cancer by leveraging the potential to uniquely target mechanisms of intrinsic and acquired resistance in BRAF V600-driven cancer cells. [0080] Southern Texas Accelerated Research Therapeutics (START; San Antonio TX) has established a panel of patient-derived xenograft (PDX) models of human CRC in immunocompromised mice, which recapitulates patient tumor biology in terms of both morphology and genomics. Evaluation of in vivo efficacy of combination treatment with Dabrafenib and Trametinib and TN0155 in a BRAF mutant CRC using these PDX models is shown in the Examples, infra.

Pharmaceutical Compositions

[0081] In another aspect, the present invention provides pharmaceutically acceptable compositions which comprise a therapeutically-effective amount of dabrafenib, trametinib and compound A, formulated together with one or more pharmaceutically acceptable carriers (additives) and/or diluents. As described in detail below, the pharmaceutical compositions of the present invention may be specially formulated for administration in solid or liquid form, including those adapted for oral administration, for example, drenches (aqueous or non- aqueous solutions or suspensions), tablets, e.g., those targeted for buccal, sublingual, and systemic absorption, boluses, powders, granules, pastes for application to the tongue.

[0082] The phrase "pharmaceutically-acceptable carrier" as used herein means a pharmaceutically-acceptable material, composition or vehicle, such as a liquid or solid filler, diluent, excipient, manufacturing aid (e.g., lubricant, talc magnesium, calcium or zinc stearate, or steric acid), or solvent encapsulating material, involved in carrying or transporting the subject compound from one organ, or portion of the body, to another organ, or portion of the body. Each carrier must be "acceptable" in the sense of being compatible with the other ingredients of the formulation and not injurious to the patient. Some examples of materials which can serve as pharmaceutically-acceptable carriers include: (1) sugars, such as lactose, glucose and sucrose; (2) starches, such as com starch and potato starch; (3) cellulose, and its derivatives, such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; (4) powdered tragacanth; (5) malt; (6) gelatin; (7) talc; (8) excipients, such as cocoa butter and suppository waxes; (9) oils, such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, com oil and soybean oil; (10) glycols, such as propylene glycol; (11) polyols, such as glycerin, sorbitol, mannitol and polyethylene glycol; (12) esters, such as ethyl oleate and ethyl laurate; (13) agar; (14) buffering agents, such as magnesium hydroxide and aluminum hydroxide; (15) alginic acid; (16) pyrogen-free water; (17) isotonic saline; (18) Ringer's solution; (19) ethyl alcohol; (20) pH buffered solutions; (21) polyesters, polycarbonates and/or polyanhydrides; and (22) other non-toxic compatible substances employed in pharmaceutical formulations. [0083] As set out above, certain embodiments of the present compounds may contain a basic functional group, such as amino or alkylamino, and are, thus, capable of forming pharmaceutically-acceptable salts with pharmaceutically-acceptable acids. The term "pharmaceutically-acceptable salts" in this respect, refers to the relatively non-toxic, inorganic and organic acid addition salts of compounds of the present invention. These salts can be prepared in situ in the administration vehicle or the dosage form manufacturing process, or by separately reacting a purified compound of the invention in its free base form with a suitable organic or inorganic acid, and isolating the salt thus formed during subsequent purification. Representative salts include the hydrobromide, hydrochloride, sulfate, bisulfate, phosphate, nitrate, acetate, valerate, oleate, palmitate, stearate, laurate, benzoate, lactate, phosphate, tosylate, citrate, maleate, fumarate, succinate, tartrate, napthylate, mesylate, glucoheptonate, lactobionate, and laurylsulphonate salts and the like.

[0084] The pharmaceutically acceptable salts of the subject compounds include the conventional nontoxic salts or quaternary ammonium salts of the compounds, e.g., from non toxic organic or inorganic acids. For example, such conventional nontoxic salts include those derived from inorganic acids such as hydrochloride, hydrobromic, sulfuric, sulfamic, phosphoric, nitric, and the like; and the salts prepared from organic acids such as acetic, propionic, succinic, glycolic, stearic, lactic, malic, tartaric, citric, ascorbic, palmitic, maleic, hydroxymaleic, phenylacetic, glutamic, benzoic, salicyclic, sulfanilic, 2-acetoxybenzoic, fumaric, toluenesulfonic, methane sulfonic, ethane disulfonic, oxalic, isothionic, and the like. [0085] In other cases, the compounds of the present invention may contain one or more acidic functional groups and, thus, are capable of forming pharmaceutically -acceptable salts with pharmaceutically-acceptable bases. The term "pharmaceutically-acceptable salts" in these instances refers to the relatively non-toxic, inorganic and organic base addition salts of compounds of the present invention. These salts can likewise be prepared in situ in the administration vehicle or the dosage form manufacturing process, or by separately reacting the purified compound in its free acid form with a suitable base, such as the hydroxide, carbonate or bicarbonate of a pharmaceutically-acceptable metal cation, with ammonia, or with a pharmaceutically-acceptable organic primary, secondary or tertiary amine. Representative alkali or alkaline earth salts include the lithium, sodium, potassium, calcium, magnesium, and aluminum salts and the like. Representative organic amines useful for the formation of base addition salts include ethylamine, diethylamine, ethylenediamine, ethanolamine, diethanolamine, piperazine and the like.

[0086] A particularly preferred salt of dabrafenib is the mesylate salt thereof. A particularly preferred solvate of trametinib is the dimethyl sulfoxide solvate thereof. A particularly preferred solvate of compound A is the succinate salt thereof. [0087] Wetting agents, emulsifiers and lubricants, such as sodium lauryl sulfate and magnesium stearate, as well as coloring agents, release agents, coating agents, sweetening, flavoring and perfuming agents, preservatives and antioxidants can also be present in the compositions.

[0088] Examples of pharmaceutically-acceptable antioxidants include: (1) water soluble antioxidants, such as ascorbic acid, cysteine hydrochloride, sodium bisulfate, sodium metabisulfite, sodium sulfite and the like; (2) oil-soluble antioxidants, such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, and the like; and (3) metal chelating agents, such as citric acid, ethylenediamine tetraacetic acid (EDTA), sorbitol, tartaric acid, phosphoric acid, and the like. [0089] Formulations of the present invention include those suitable for oral, nasal, topical (including buccal and sublingual), rectal, vaginal and/or parenteral administration. The formulations may conveniently be presented in unit dosage form and may be prepared by any methods well known in the art of pharmacy. The amount of active ingredient which can be combined with a carrier material to produce a single dosage form will vary depending upon the host being treated, the particular mode of administration. The amount of active ingredient which can be combined with a carrier material to produce a single dosage form will generally be that amount of the compound which produces a therapeutic effect. Generally, out of one hundred per cent, this amount will range from about 0.1 per cent to about ninety-nine percent of active ingredient, preferably from about 5 per cent to about 70 per cent, most preferably from about 10 percent to about 30 percent. [0090] In certain embodiments, a formulation of the present invention comprises an excipient selected from the group consisting of cyclodextrins, celluloses, liposomes, micelle forming agents, e.g., bile acids, and polymeric carriers, e.g., polyesters and polyanhydrides; and a compound of the present invention. In certain embodiments, an aforementioned formulation renders orally bioavailable a compound of the present invention. [0091] Methods of preparing these formulations or compositions include the step of bringing into association a compound of the present invention with the carrier and, optionally, one or more accessory ingredients. In general, the formulations are prepared by uniformly and intimately bringing into association a compound of the present invention with liquid carriers, or finely divided solid carriers, or both, and then, if necessary, shaping the product. [0092] Formulations of the invention suitable for oral administration may be in the form of capsules, cachets, pills, tablets, lozenges (using a flavored basis, usually sucrose and acacia or tragacanth), powders, granules, or as a solution, suspension or solid dispersion in an aqueous or non-aqueous liquid, or as an oil-in-water or water-in-oil liquid emulsion, or as an elixir or syrup, or as pastilles (using an inert base, such as gelatin and glycerin, or sucrose and acacia) and/or as mouth washes and the like, each containing a predetermined amount of a compound of the present invention as an active ingredient. A compound of the present invention may also be administered as a bolus, electuary or paste.

[0093] In solid dosage forms of the invention for oral administration (capsules, tablets, pills, dragees, powders, granules, trouches and the like), the active ingredient is mixed with one or more pharmaceutically-acceptable carriers, such as sodium citrate or dicalcium phosphate, and/or any of the following: (1) fdlers or extenders, such as starches, lactose, sucrose, glucose, mannitol, and/or silicic acid; (2) binders, such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinyl pyrrolidone, sucrose and/or acacia; (3) humectants, such as glycerol; (4) disintegrating agents, such as agar-agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate; (5) solution retarding agents, such as paraffin; (6) absorption accelerators, such as quaternary ammonium compounds and surfactants, such as poloxamer and sodium lauryl sulfate; (7) wetting agents, such as, for example, cetyl alcohol, glycerol monostearate, and non-ionic surfactants; (8) absorbents, such as kaolin and bentonite clay; (9) lubricants, such as talc, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate, zinc stearate, sodium stearate, stearic acid, and mixtures thereof; (10) coloring agents; and (11) controlled release agents such as crospovidone or ethyl cellulose. In the case of capsules, tablets and pills, the pharmaceutical compositions may also comprise buffering agents. Solid compositions of a similar type may also be employed as fillers in soft and hard-shelled gelatin capsules using such excipients as lactose or milk sugars, as well as high molecular weight polyethylene glycols and the like.

[0094] A tablet may be made by compression or molding, optionally with one or more accessory ingredients. Compressed tablets may be prepared using binder (for example, gelatin or hydroxypropylmethyl cellulose), lubricant, inert diluent, preservative, disintegrant (for example, sodium starch glycolate or cross-linked sodium carboxymethyl cellulose), surface -active or dispersing agent. Molded tablets may be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent.

[0095] The tablets, and other solid dosage forms of the pharmaceutical compositions of the present invention, such as dragees, capsules, pills and granules, may optionally be scored or prepared with coatings and shells, such as enteric coatings and other coatings well known in the pharmaceutical-formulating art. They may also be formulated so as to provide slow or controlled release of the active ingredient therein using, for example, hydroxypropylmethyl cellulose in varying proportions to provide the desired release profile, other polymer matrices, liposomes and/or microspheres. They may be formulated for rapid release, e.g., freeze-dried. They may be sterilized by, for example, filtration through a bacteria-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions which can be dissolved in sterile water, or some other sterile injectable medium immediately before use. These compositions may also optionally contain opacifying agents and may be of a composition that they release the active ingredient(s) only, or preferentially, in a certain portion of the gastrointestinal tract, optionally, in a delayed manner. Examples of embedding compositions which can be used include polymeric substances and waxes. The active ingredient can also be in micro-encapsulated form, if appropriate, with one or more of the above -described excipients.

[0096] Liquid dosage forms for oral administration of the compounds of the invention include pharmaceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups and elixirs. In addition to the active ingredient, the liquid dosage forms may contain inert diluents commonly used in the art, such as, for example, water or other solvents, solubilizing agents and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (in particular, cottonseed, groundnut, com, germ, olive, castor and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof.

[0097] Besides inert diluents, the oral compositions can also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, coloring, perfuming and preservative agents.

[0098] Suspensions, in addition to the active compounds, may contain suspending agents as, for example, ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth, and mixtures thereof.

[0099] Examples of suitable aqueous and nonaqueous carriers which may be employed in the pharmaceutical compositions of the invention include water, ethanol, polyols (such as glycerol, propylene glycol, polyethylene glycol, and the like), and suitable mixtures thereof, vegetable oils, such as olive oil, and injectable organic esters, such as ethyl oleate. Proper fluidity can be maintained, for example, by the use of coating materials, such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants. [00100] These compositions may also contain adjuvants such as preservatives, wetting agents, emulsifying agents and dispersing agents. Prevention of the action of microorganisms upon the subject compounds may be ensured by the inclusion of various antibacterial and antifungal agents, for example, paraben, chlorobutanol, phenol sorbic acid, and the like. It may also be desirable to include isotonic agents, such as sugars, sodium chloride, and the like into the compositions. [00101] When the compounds of the present invention are administered as pharmaceuticals, to humans and animals, they can be given per se or as a pharmaceutical composition containing, for example, 0.1 to 99% (more preferably, 10 to 30%) of active ingredient in combination with a pharmaceutically acceptable carrier.

[00102] The compounds of the present invention and/or the pharmaceutical compositions of the present invention, are formulated into pharmaceutically-acceptable dosage forms by conventional methods known to those of skill in the art.

[00103] Actual dosage levels of the active ingredients in the pharmaceutical compositions of this invention may be varied so as to obtain an amount of the active ingredient which is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient.

[00104] The selected dosage level will depend upon a variety of factors including the activity of the particular compound of the present invention employed, or the ester, salt or amide thereof, the route of administration, the time of administration, the rate of excretion or metabolism of the particular compound being employed, the rate and extent of absorption, the duration of the treatment, other drugs, compounds and/or materials used in combination with the particular compound employed, the age, sex, weight, condition, general health and prior medical history of the patient being treated, and like factors well known in the medical arts. [00105] A physician or veterinarian having ordinary skill in the art can readily determine and prescribe the effective amount of the pharmaceutical composition required. For example, the physician or veterinarian could start doses of the compounds of the invention employed in the pharmaceutical composition at levels lower than that required in order to achieve the desired therapeutic effect and gradually increase the dosage until the desired effect is achieved.

[00106] In general, a suitable daily dose of the combination of the invention will be that amount of each compound which is the lowest dose effective to produce a therapeutic effect. Such an effective dose will generally depend upon the factors described above. [00107] In another aspect, the present invention provides pharmaceutically acceptable compositions which comprise a therapeutically -effective amount of one or more of the subject compounds, as described above, formulated together with one or more pharmaceutically acceptable carriers (additives) and/or diluents.

Examples

Example 1

Dabrafenib, Trametinib and Compound A

[00108] Dabrafenib is synthesized according to example 58a of WO2009/137391.

Trametinib is synthesized according to example 4-1 of W02005/121142. Compound A is synthesized according to example 69 of WO2015/107495. WO2009/137391, WO2015/066188 and WO2015/107495, are herein incorporated by reference in their entirety. The utility of a combination of Dabrafenib, trametinib and Compound A described herein can be evidenced by testing in the following examples.

Example 2

In vivo efficacy of Dabrafenib and Tranetinib and comnound A combination treatment in a colorectal PDX mouse trial

[00109] Dabrafenib (LIQ288) was formulated as a suspension in 0.2% Tween 80 + 0.5% HPMC in water, with homogenization and at a final pH of 8. This was prepared at 1.5mg/ml concentration, and has stability of 23 days when stored in the dark at 4°C. It is dosed by oral gavage at lOml/kg volume twice daily.

[00110] Trametinib (CFF272; DMSO solvate) was formulated as a suspension in 0.2% Tween 80 + 0.5% HPMC in water, with overnight stirring and at a final pH of 8. This is prepared at 0.03mg/ml and 0.0075mg/ml concentrations, and has stability of 2 weeks when stored in the dark at 4°C. It is dosed by oral gavage at lOml/kg volume once daily.

[00111] Compound A (TN0155) was formulated as a suspension in 0.1% Tween 80 + 0.5%MC in water. This is prepared at lmg/ml concentration, and has stability of 7 days when stored in the dark at 4°C. It is dosed by oral gavage at lOml/kg volume twice daily. [00112] Cetuximab was supplied as a 2mg/ml stock per clinical formulation. It is stored at

4°C and dosed by intraperitoneal injection at lOml/kg volume twice weekly.

[00113] Female athymic nude mice (CRL:Nu(NCr)-foxnlnu; Charles River Labs, MA) were housed in a temperature and humidity-controlled vivarium with a 12 hour light/dark cycle, and were provided with food and water ad libitum.

[00114] Patient-derived xenograft (PDX) models of human CRC were established by direct implantation of patient CRC tumor tissue subcutaneously into nude mice (Table 1). PDX models were maintained through in vivo serial passaging. Table 1

[00115] RNA and DNA were extracted from PDX tumor samples of donor mice using the

Qiagen AllPrep DNA/RNA mini kit (Qiagen #80204). RNA expression and mutation calls were derived from Illumina RNAseq data, and copy number and CIN analysis was derived from the profiling of DNA on low pass WGS data. Model identities were verified against patient tumor DNA using a panel of 48 intergenic SNPs (SNP48) run on the Fluidigm platform.

[00116] The above 18 CRC PDX models and 9 treatment arms including untreated controls were included in the mouse clinical trial. The treatment arms and dosage regimen are shown in Table 2.

Table 2

[00117] A cohort of mice was implanted subcutaneously with tumor fragments from each

PDX model (typically p4-p9). Each individual mouse is assigned to a treatment group for dosing, or to the untreated control group, once its tumor volume reaches 200-250 mm³. One animal per PDX model was assigned to each treatment arm. Once enrolled into treatment groups, tumor volumes were measured twice weekly by caliper, and body weights were recorded twice weekly. End of study per model is defined as minimum 28 days treatment, or duration for untreated tumor to reach 1500 mm³, or duration for 2 doublings of untreated tumor, whichever is slower. [00118] At termination of study, tumor fragments were collected from every treated and control animal. Frozen tumor samples were stored at -80°C until analyses.

[00119] Change in body weight (BW) was calculated as (BWt - BWinitiai)/BWinitiai x 100%.

Data is presented as percent body weight change from the day of treatment initiation. [00120] Tumor volume (TV) was calculated using the formula: Length x Width2 /2. The response was determined by comparing tumor volume change at time t to its baseline: ATV_t =

(TV, - TV initial) / TVi„i_tial X 100%.

[00121] Tumor growth kinetics in response to treatment is represented by Best Minimum

Response (BestMinResponse) and Best Average Response (BestAvgResponse). These two parameters are used to determine the response category for each model.

[00122] BestMinResponse was defined as the minimum value of ATV_t for t > 10 d. For each time t, the average of ATV_t from t = 0 to t was also calculated. We defined the BestAvgResponse as the minimum value of this average for t > 10 d. This metric captures a combination of speed, strength and durability of response into a single value. [00123] The response categories were adapted from RECIST criteria (Therasse et al,

2000), and defined as follows (applied in this order): Complete Response (CR) = BestAvgResponse < -40% and BestMinResponse < -95%; Partial Response (PR) = BestAvgResponse < -20% and BestMinResponse < -50%; Stable Disease (SD) = BestAvgResponse < 30% and BestMinResponse < 35%; Progressive Disease (PD) = did not meet any of the criteria above; CR- PD, PR- PD, SD- PD were applied if a response was observed but resistance emerged.

[00124] Mice that were sacrificed because of an adverse event were labeled as “toxic” and excluded from the data set.

[00125] All data were compiled into a single Spotfire (TIBCO Software Inc) library. [00126] Correlation analyses between data sets were performed within Spotfire using the regression modelling tool. All R² values and P values represented are as generated within Spotfire following regression analysis and the F-Statistic tool.

[00127] In vivo efficacy of Dabrafenib and Trametinib (LIQ288+CFF272) combination treatment was evaluated in 18 unique CRC PDX models harboring BRAF V600E mutation. One model (30069-HX) was discovered to harbor a BRAF F585V mutation instead and was excluded from analysis. [00128] Treatment with double combination of Dabrafenib and Trametinib (LIQ288+CFF272), a standard of care treatment for BRAF mutant CRC at clinically relevant dosages, resulted in 2 PR and 3 SD out of the 17 BRAF V600E CRC PDX models in this mouse trial panel (Figure 1). [00129] Treatment with triple combination of Dabrafenib, Trametinib and TN0155

(LIQ288+CFF272+TN0155) achieved 2 PR and 6 SD in a subset of 15 models. Two models exhibited >30% body weight loss over the course of treatment and were excluded from analysis. This response rate is comparable to the other clinically relevant triple combination of Dabrafenib, Trametinib and the EGFR inhibitor, Cetuximab (LIQ288+CFF272+cetuximab), which resulted in 1 PR and 7 SD in the set of 17 models.

[00130] Kaplan-Meier analysis of tumor doubling time is another measure of efficacy in this mouse trial (Figure 2). While triple combination treatment of Dabrafenib + Trametinib + TN0155 extended tumor doubling time compared to untreated PDXs (p<0.05), it did not achieve statistically significant improvement over the double Dabrafenib + Trametinib or the triple Dabrafenib + Trametinib + Cetuximab combinations (p=0.33).

[00131] Slight body weight loss were experienced in subset of models across these treatments regimens (Figure 3). Animals showing >30% BW loss were removed from study and excluded from analysis.

[00132] Triple combination treatment of Dabrafenib + Trametinib + TN0155 demonstrated tumor growth inhibition efficacy in a representative panel of BRAF V600E- mutant colorectal PDX models, showing response rate which is superior or comparable to current clinical regimens of Dabrafenib + Trametinib double combination or Dabrafenib + Trametinib + Cetuximab triple combination. This result supports the use of the Dabrafenib + Trametinib + TN0155 combination treatment regimen in patients with BRAF-mutant colorectal cancer.

[00133] It is understood that the Examples and embodiments described herein are for illustrative purposes only and that various modifications or changes in light thereof will be suggested to persons skilled in the art and are to be included within the spirit and purview of this application and scope of the appended claims.

Claims

What is claimed is:

1. A pharmaceutical combination comprising: N-(3-(5-(2-aminopyrimidin-4-yl)-2-(tert- butyl)thiazol-4-yl)-2-fluorophenyl)-2,6-difluorobenzenesulfonamide (dabrafenib), or a pharmaceutically acceptable salt thereof; N-(3-(3-cyclopropyl-5-((2-fluoro-4- iodophenyl)amino)-6,8-dimethyl-2,4,7-trioxo-3,4,6,7-tetrahydropyrido[4,3-d]pyrimidin- l(2H)-yl)phenyl)acetamide (trametinib), or a pharmaceutically acceptable salt thereof; and (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8- azaspiro[4.5]decan-4-amine (compound A), or a pharmaceutically acceptable salt thereof.

2. The combination of claim 1, wherein N-(3-(5-(2-aminopyrimidin-4-yl)-2-(tert- butyl)thiazol-4-yl)-2-fluorophenyl)-2,6-difluorobenzenesulfonamide (dabrafenib), or a pharmaceutically acceptable salt thereof, N-(3-(3-cyclopropyl-5-((2-fluoro-4- iodophenyl)amino)-6,8-dimethyl-2,4,7-trioxo-3,4,6,7-tetrahydropyrido[4,3-d]pyrimidin- l(2H)-yl)phenyl)acetamide (trametinib), or a pharmaceutically acceptable salt thereof, and (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8- azaspiro[4.5]decan-4-amine (compound A), or a pharmaceutically acceptable salt thereof, are administered separately, simultaneously or sequentially, in any order.

3. The pharmaceutical combination according to claim 1 or 2, which is for oral administration.

4. The pharmaceutical combination according to any one of claims 1 to 3, wherein N-(3-(5- (2-aminopyrimidin-4-yl)-2-(tert-butyl)thiazol-4-yl)-2-fluorophenyl)-2,6- difluorobenzenesulfonamide (dabrafenib) is in an oral dosage form.

5. The pharmaceutical combination according to any one of claims 1 to 4, wherein N-(3-(3- cyclopropyl-5-((2-fluoro-4-iodophenyl)amino)-6,8-dimethyl-2,4,7-trioxo-3,4,6,7- tetrahydropyrido[4,3-d]pyrimidin-l(2H)-yl)phenyl)acetamide (trametinib) is in an oral dosage form.

6. The pharmaceutical combination according to any one of claims 1 to 4, wherein (3S,4S)-8- (6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8- azaspiro[4.5]decan-4-amine (compound A) is in an oral dosage form.

7. A pharmaceutical composition or a commercial package comprising the pharmaceutical combination according to any one of the preceding claims and at least one pharmaceutically acceptable carrier.

8. A pharmaceutical combination according to any one of claims 1 to 6 or the pharmaceutical composition or the commercial package according to claim 7 for use in the treatment of cancer.

9. The pharmaceutical combination or the pharmaceutical composition or the commercial package for use according to claim 8, wherein the cancer is selected from breast cancer, cholangiocarcinoma, colorectal cancer (CRC), melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer.

10. The pharmaceutical combination or the pharmacutical composition or the commercial package for use according to claim 8, wherein the cancer is advanced or metastatic colorectal cancer.

11. The pharmaceutical combination of claim 10 wherein the cancer is BRAF gain of function CRC or BRAF V600E, V600D or V600K CRC.

12. Use of the pharmaceutical combination according to any one of claims 1 to 6 or the pharmaceutical composition or commercial package according to claim 7 for the manufacture of a medicament for the treatment of cancer.

13. The use of the pharmaceutical combination or the pharmaceutical composition according to claim 12 wherein the cancer is selected from breast cancer, cholangiocarcinoma, colorectal cancer, melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer, optionally wherein the cancer is advanced or metastatic colorectal cancer, optionally wherein the cancer is BRAF gain of function CRC or BRAF V600E, V600D or V600K CRC.

14. A method of treating a cancer selected from breast cancer, cholangiocarcinoma, colorectal cancer, melanoma, non-small cell lung cancer, ovarian cancer and thyroid cancer comprising administrating to a patient in need thereof a pharmaceutical combination or commercial package according to any one of claims 1 to 6 or the pharmaceutical composition according to claim 7.

15. The method of claim 14 wherein the colorectal cancer is advanced or metastatic colorectal cancer.

16. The method of claim 15 wherein the colorectal cancer is BRAF gain of function CRC or BRAF V600E, V600D or V600K CRC.

17. The method of claim 14, wherein N-(3-(5-(2-aminopyrimidin-4-yl)-2-(tert-butyl)thiazol- 4-yl)-2-fluorophenyl)-2,6-difluorobenzenesulfonamide (dabrafenib) is administered orally at a dose of about from about 1 to about 150 mg per day.

18. The method of claim 14, wherein N-(3-(3-cyclopropyl-5-((2-fluoro-4-iodophenyl)amino)- 6,8-dimethyl-2,4,7-trioxo-3,4,6,7-tetrahydropyrido[4,3-d]pyrimidin-l(2H)- yl)phenyl)acetamide (trametinib) is administered orally at a dose of from about 0.5 to about 2 mg per day (e.g. about 0.5, 1 or 2 mg per day and, e.g., about 0.5635, 1.127 or 2.254 mg in the form of trametinib dimethyl sulfoxide per day).

19. The method of claim 14, wherein (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4- yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine (compound A) is adminstered orally at a dose of from about 1.5 mg per day, or 3 mg per day, or 6 mg per day, or 10 mg per day, or 20 mg per day, or 30 mg per day, or 40 mg per day, or 50 mg per day, or 60 mg per day, or 70 mg per day, or 80 mg per day, or 90 mg per day to about 100 mg per day.

20. The method of claim 19 wherein the dose per day of compound A is on a 21 day cycle of 2 weeks on drug followed by 1 week off drug.