TREATING ACUTE MYELOID LEUKEMIA

The present invention relates to the use of Bl 6727 or a salt thereof or the hydrate thereof for treating patients suffering from acute myeloid leukemia (AML) comprising a high dose of Bl 6727 administered according to a specific dosage schedule, optionally in combination with cytarabine.

Background of the invention

Acute myeloid leukemia (AML), also known as acute myelogenous leukemia, is a cancer of the myeloid line of blood cells, characterized by the rapid growth of abnormal white blood cells that accumulate in the bone marrow and interfere with the production of normal blood cells. As an acute leukemia, AML progresses rapidly and is typically fatal within weeks or months if left untreated. AML is the most prevalent form of adult leukemia, particularly among the elderly and is slightly more common in men than women. There is an estimated prevalence of 30,000 cases of AML in the US and 47,000 in the EU.

The incidence of AML increases with age with a median age at diagnosis of 67 years. The global incidence CAGR for AML out to 2013 is 1 .4%. An aging population, along with an increased incidence of treatment-related AML in cancer survivors, currently accounting for 10-20% of all AML cases, is expected to drive the incidence of AML. In addition, there is some geographic variation in the incidence of AML. In adults, the highest rates are seen in North America, Europe, and Oceania, while adult AML is rarer in Asia and Latin America.

AML accounts for approximately 1 .2% of all cancer deaths. The 5 year survival rates for AML are low, driven by therapy failure and patients relapsing. Among patients <65 the 5 year survival rate is 34.4%, among patients >65 it is only 5%.

According to the French-American-British (FAB) classification system AML is divided into subtypes (M0 to M8), based on the type of cell from which the leukemia developed and its degree of maturity. The WHO classification incorporates of genetic abnormalities into diagnostic algorithms for the diagnosis of AML. This classification is done by examining the appearance of the malignant cells under light microscopy and by using cytogenetics and molecular genetics to characterize any underlying chromosomal abnormalities or genetic changes. The subtypes impact on prognoses, responses to therapy and treatment decisions.

The WHO subtypes are as follows:

Acute myeloid leukemia and related neoplasms

• Acute myeloid leukemia with recurrent genetic abnormalities

o AML with t(8;21 )(q22;q22); RUNX1-RUNX1 T1

o AML with inv(16)(p13.1 q22) or t(16; 16)(p13.1 ;q22); CBFB-MYH11 o APL with t(15; 17)(q22;q12); PML-RARA

o AML with t(9; 1 1 )(p22;q23); MLLT3-MLL

o AML with t(6;9)(p23;q34); DEK-NUP214

o AML with inv(3)(q21 q26.2) or t(3;3)(q21 ;q26.2); RPN1-EVI1 o AML (megakaryoblastic) with t(1 ;22)(p13;q13); RBM15-MKL1 o Provisional entity: AML with mutated NPM1

o Provisional entity: AML with mutated CEBPA

• Acute myeloid leukemia with myelodysplasia-related changes

• Therapy-related myeloid neoplasms

• Acute myeloid leukemia, not otherwise specified

o AML with minimal differentiation

o AML without maturation

o AML with maturation

o Acute myelomonocytic leukemia

o Acute monoblastic/monocytic leukemia

o Acute erythroid leukemia

^■ Pure erythroid leukemia

^■ Erythroleukemia, erythroid/myeloid

o Acute megakaryoblastic leukemia

o Acute basophilic leukemia

o Acute panmyelosis with myelofibrosis • Myeloid sarcoma

• Myeloid proliferations related to Down syndrome

o Transient abnormal myelopoiesis

o Myeloid leukemia associated with Down syndrome

• Blastic plasmacytoid dendritic cell neoplasm

The efficacy of chemotherapeutic agents can be improved by improving the dosage schedule and/or using combination therapies with other compounds. Even if the concept of combining several therapeutic agents or improved dosage schedules already has been suggested, there is still a need for new and efficient therapeutic concepts for the treatment of cancer diseases, which show advantages over standard therapies.

Bl 6727 is a highly potent and selective inhibitor of the serine-threonine Polo like kinase 1 (Plk1 ), a key regulator of cell-cycle progression. Bl 6727 is a second- generation dihydropteridinone derivative with distinct pharmacokinetic (PK) properties. The problem underlying this invention was to develop improved dosage schedules for monotherapy and combinations of Bl 6727 and cytarabine in AML with maximal activity and limited toxicity.

Bl 6727 (I) is known as the compound N-[trans-4-[4-(cyclopropylmethyl)-1 - piperazinyl]cyclohexyl]-4-[[(7R)-7-ethyl-5,6,7,8-tetrahydro- 5-methyl-8-(1 -methylethyl)-

6-oxo-2-pteridinyl]amino]-3-methoxy-benzamide,

(I). This compound is disclosed in WO 04/076454. Furthermore, trihydrochloride salt forms and hydrates thereof are known from WO 07/090844. They possess properties which make those forms especially suitable for pharmaceutical use. The above mentioned patent applications further disclose the use of this compound or its monoethanesulfonate salt for the preparation of pharmaceutical compositions intended especially for the treatment of diseases characterized by excessive or abnormal cell proliferation.

Cytarabine is inter alia known by the brand names Cytosar-U, Tarabine PFS, DepoCyte and AraC. Cytarabine is mainly used in the treatment of acute myeloid leukaemia, acute lymphocytic leukaemia (ALL) and in lymphomas.

Summary of the Invention

In clinical trials with patients suffering from AML it has been found that Bl 6727 can be administered in higher dosages and shorter intervals than in patients with solid tumors. In addition it has been found that Bl 6727 can be administered in these higher dosages and shorter intervals in combination with Cytarabine, which has a profile of side effects which is similar to that of Bl 6727 without potentiation of those side effects.

Accordingly, a first object of the present invention is a method of treating AML in patients suffering from AML characterized by administering 350 to 500 mg, preferably 350, 400, 450 or 500 mg of Bl 6727 or a pharmaceutically acceptable salt thereof or a hydrate thereof per administration. Preferably equal doses of Bl 6727 are administered at at least two days during a 4 week treatment cycle, preferably at day 1 and at one of the days 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 , more preferably at day 1 and at day 15, during a 4 week treatment cycle.

Another object of the present invention refers to Bl 6727 or a pharmaceutically acceptable salt thereof or a hydrate thereof for the use in treating AML in patients suffering from AML characterized by administering 350 to 500 mg, preferably 350, 400, 450 or 500 mg of Bl 6727 per administration. Preferably equal doses of Bl 6727 are administered at at least two days during a 4 week treatment cycle, preferably at day 1 and at one of the days 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 , more preferably at day 1 and at day 15, during a 4 week treatment cycle.

Another object of the present invention refers to the use of Bl 6727 or a

pharmaceutically acceptable salt thereof or a hydrate thereof for the manufacture of a medicament for treating AML wherein the medicament is prepared for administration of 350 to 500 mg, preferably 350, 400, 450 or 500 mg of Bl 6727 per administration. Preferably equal doses of Bl 6727 are administered at at least two days during a 4 week treatment cycle, preferably at day 1 and at one of the days 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 , more preferably at day 1 and at day 15, during a 4 week treatment cycle.

Another object of the present invention is a method of treating AML characterized by a dosage schedule (I) comprising or consisting of

a) administration of an effective amount of Bl 6727 or a pharmaceutically

acceptable salt thereof or a hydrate thereof at at least two days during a 4 week treatment cycle and

b) administration of an effective amount of Cytarabine at least at one day of the said 4 week treatment cycle

to a patient suffering from AML.

Another object of the present invention is a method of treating AML in patients suffering from AML (dosage schedule (II)) characterized by dosage schedule (I) wherein Bl 6727 or a pharmaceutically acceptable salt thereof or a hydrate thereof is administered at day 1 and at one of the days 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 during a 4 week treatment cycle.

A another object of the present invention is a method of treating AML in patients suffering from AML (dosage schedule (III)) characterized by one of the above dosage schedules (dosage schedule (I) or (II)) wherein 350 to 500 mg, preferably 350, 400, 450 or 500 mg, most preferably 350 mg of Bl 6727 or a pharmaceutically acceptable salt thereof or a hydrate thereof are administered per day of administration.

Another object of the present invention is a method of treating AML in patients suffering from AML (dosage schedule (IV)) characterized by one of the above dosage schedules (dosage schedule (I), (II) or (III)) wherein Cytarabine is administered at 10 days of the said 4 week treatment cycle.

Another object of the present invention is a method of treating AML in patients suffering from AML (dosage schedule (V)) characterized by one of the above dosage schedules (dosage schedule (I), (II), (III) or (IV)) wherein Cytarabine is administered from day 1 to 10 of the said 4 week treatment cycle.

Another object of the present invention is a method of treating AML in patients suffering from AML (dosage schedule (VI)) characterized by one of the above dosage schedules (dosage schedule (I), (II), (III), (IV) or (V)) wherein 40 mg Cytarabine are administered per day of administration.

Another object of the invention refers to Bl 6727 or a pharmaceutically acceptable salt thereof or a hydrate thereof for the use in treating AML in patients suffering from AML characterized in that Bl 6727 or a pharmaceutically acceptable salt thereof or a hydrate thereof is administered according to one of the dosage schedules (I) to (VI).

Another object of the invention refers to Cytarabine for the use in treating AML in patients suffering from AML characterized in that Cytarabine is administered according to one of the dosage schedules (I) to (VI).

Another object of the invention refers to the use of Bl 6727 or a pharmaceutically acceptable salt thereof or a hydrate thereof for the manufacture of a medicament for treating AML in patients suffering from AML wherein the medicament is prepared for administration according to one of the dosage schedules (I) to (VI). Another object of the invention refers to the use of Cytarabine for the manufacture of a medicament for treating AML in patients suffering from AML wherein the

medicament is prepared for administration according to one of the dosage schedules (I) to (VI).

Another object of the invention is a pharmaceutical composition comprising an effective amount of Bl 6727 and an effective amount of Cytarabine together with an instruction for administration of both active ingredients to a patient suffering from AML, wherein according to said instruction Bl 6727 is to be administered according to the above mentioned dosage schedules.

Another object of the invention is a pharmaceutical kit, comprising a first

compartment which comprises an effective amount of Bl 6727 and a second compartment which comprises an effective amount of Cytarabine, together with an instruction for administration of both active ingredients to a patient suffering from AML, wherein according to said instruction Bl 6727 (preferably 350, 400, 450 or 500 mg, more preferably 350 mg) and Cytarabine (preferably 40 mg/day) is to be administered according to one of the above mentioned dosage schedules.

Another object of the present invention is the compound Bl 6727 for its

coadministration with Cytarabine to a patient suffering from AML, characterized in that Bl 6727 (preferably 350, 400, 450 or 500 mg, more preferably 350 mg) and Cytarabine (preferably 40 mg/day) is to be administered according to above mentioned dosage schedules.

Another object of the present invention is the use of Bl 6727 for preparation of a pharmaceutical composition comprising an effective amount of Bl 6727 and

Cytarabine together with an instruction for administration of both active ingredients to a patient suffering from AML, wherein according to said instruction Bl 6727

(preferably 350, 400, 450 or 500 mg, more preferably 350 mg) and Cytarabine (preferably 40 mg/day) is to be administered according to above mentioned dosage schedules. Another object of the present invention is the use of Bl 6727 for preparation of a pharmaceutical kit, comprising a first compartment which comprises an effective amount of Bl 6727 and a second compartment which comprises Cytarabine, optionally together with an instruction for administration of both active ingredients to a patient suffering from AML, wherein according to said instruction Bl 6727 (preferably 350, 400, 450 or 500 mg, more preferably 350 mg) and Cytarabine (preferably 40 mg/day) is to be administered according to above mentioned dosage schedules.

Detailed Description of the Invention

For example, the administration of Bl 6727 at at least two days during a 4 week treatment cycle means that Bl 6727 is administered at two different days during a 4 week treatment.

The administration of an effective amount of Cytarabine at at least one day of the said 4 week treatment cycle means that during the 4 week treatment cycle in which Bl 6727 is adminidstered at least two times, also Cytarabine is administered at least at one day.

The administration of Bl 6727 at day 1 and 15 during a 4 week treatment cycle means that one dosage of Bl 6727 or a pharmaceutically acceptable salt or a hydrate thereof is administered at day one and the second dosage is administered at day 15 to the patient suffering from AML in the four week treatment cycle.

The administration of Cytarabine from days 1 to 10 during a 4 week treatment cycle means that a daily dosage of Cytarabine or a pharmaceutically acceptable salt thereof is administered to the patient suffering from AML beginning at day one and ending with the last dosage at day 10 in the four week treatment cycle.

Accordingly a complete four week treatment cycle according to one of the above mentioned dosage schedules may comprise the following administrations: Day 1 : one dosage of Bl 6727(e.g. 350 mg) and two dosages of Cytarabine (20 mg bid);

Day 2 to day 10 (including): two dosages of 20 mg Cytarabine per day;

Day 1 1 to day 14 (including): no administration of Bl 6727 and Cytarabine;

Day 15: one dosage of Bl 6727 (e.g. 350 mg);

Day 16 to day 28 (including): no administration of Bl 6727 and Cytarabine.

This treatment cycle can be repeated as long as patients are eligible for repeated cycles, i.e. until progression of disease and as long as neither patient nor investigator requests treatment discontinuation.

The instruction for coadministration may be in any form suitable for pharmaceuticals, e.g. in form of a leaflet added to the dosage form within secondary packaging or an imprint on the primary or secondary packaging.

Dosages /Bl 6727:

For intraveneous treatment Bl 6727 may be administered to the human patient in a daily dose of 350 to 500 mg/application, preferably 350, 400, 450 or 500

mg/application, particularly preferred in combination with cytarabine (20 mg bid days 1 -10) at a dose of 350 mg/application. For instance, Bl 6727 can be administered as a slow intravenous infusion over several hours, e.g. over about 1 , 2, 4, 6, 10, 12 or 24 hours, preferrably about 1 or 2 hours.

Dosages / Cytarabine:

Cytarabine may be administered daily in a total dose of 10 to 150 mg, e.g 20, 30, 40, 50 mg one or two times daily or 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, 1 10, 120, 130, 140 or 150 mg once a day. The total daily dose may also be devided into two or three subdoses to be taken within one day. Preferably, the oral daily dose is administered in a single dose of 40 mg or in two doses of 20 mg each.

However, it may optionally be necessary to deviate from the dosage amounts specified for Bl 6727 and Cytarabine, depending on the body weight or method of administration, the individual response to the medication, the nature of the

formulation used and the time or interval over which it is administered. Thus, in some cases, it may be sufficient to use less than the minimum quantity specified above, while in other cases the upper limit specified will have to be exceeded. When large amounts are administered it may be advisable to spread them over the day in a number of single doses. For example, in intensive treatment schedules up to 4000 mg/qm, preferably up to up to 3000 mg/qm body surface area of cytarabine can be administered.

Dosage Forms and Formulation Aspects

Regarding any aspects of the invention for Bl 6727 pharmaceutically acceptable salts or hydrates thereof may be used, preferably trihydrochloride salt forms and hydrates thereof as disclosed in WO 07/090844. Dosages or amounts of the actives provided in the context of this invention refer in any case to the free base equivalent, that is Bl 6727 in the free base form.

The term "therapeutically effective amount" shall mean that amount of a drug or pharmaceutical agent that will elicit the biological or medical response of a tissue system, animal or human that is being sought by a researcher or clinician, resulting in a beneficial effect for at least a statistically significant fraction of patients, such as a improvement of symptoms, a cure, a reduction in disease load, reduction in tumor mass or leukaemia cell numbers, extension of life, or improvement in quality of life.

Day 1 of a 4 week treatment cycle is defined as that day at which the first dose of Bl 6727 or Cytarabine is administered.

The term "relapsed AML" is defined as reappearance of leukaemic blasts in the blood or > 5% blasts in the bone marrow after CR (complete remission) not attributable to any other cause. For patients presenting with relapsed AML, >5% blasts on baseline bone marrow assessment is required. The term "refractory AML" is defined as a failure to achieve a CR or CRi (complete remission with incomplete blood recovery) after previous therapy. Any number of prior anti-leukemia schedules is allowed.

The term "complete remission" is defined as morphologically leukaemia free state (i.e. bone marrow with < 5% blasts by morphologic criteria and no Auer rods, no evidence of extramedullary leukaemia) and absolute neutrophil count > 1 ,000/μΙ_ and platelets > 100,000/μΙ_.

The term "complete remission with incomplete blood recovery" is defined as morphologically leukaemia free state (i.e. bone marrow with < 5% blasts by morphologic criteria and no Auer rods, no evidence of extramedullary leukaemia) and neutrophil count < 1 ,000/μΙ_ or platelets < 100,000/μΙ_ in the blood.

AML patients who are considered ineligible for intensive treatment constitute an accepted subgroup although no validated algorithm has been established to determine a patient's eligibility for intensive treatment. As reflected in current practice guidelines (NCCN Clinical practice Guidelines in Oncology™, Acute Myeloid

Leukemia V.2.2021 ), the patient's age and duration of previous remission are important variables to assess a patient's eligibility for intensive treatment. However, many other factors will contribute to the medical assessment (e.g. AML cytogenetics, performance status, prior stem cell transplantation, concomitant diagnoses). Thus, an assessment of ineligibility for intensive treatment is required to ensure a defined and homogeneous patient population. This assessment will be performed for each patient and is based on a series of defined criteria identified through an extensive literature review of the prognostic factors predictive of an unfavourable outcome after treatment with intensive chemotherapy combination with different schedules of cytarabine and anthracycline

Within the present invention the term "AML" is to be understood to encompass all forms of acute myeloid leukemia and related neoplasms according to the 2008 revision of theWorld Health Organization (WHO) classification of myeloid neoplasms and acute leukemia. Further all above mentioned subgroups in their relapsed or refractory state are encompased. These are:

• Acute myeloid leukemia with recurrent genetic abnormalities

o AML with t(8;21 )(q22;q22); RUNX1-RUNX1 T1

o AML with inv(16)(p13.1 q22) or t(16; 16)(p13.1 ;q22); CBFB-MYH11 o AML with t(9; 1 1 )(p22;q23); MLLT3-MLL

o AML with t(6;9)(p23;q34); DEK-NUP214

o AML with inv(3)(q21 q26.2) or t(3;3)(q21 ;q26.2); RPN1-EVI1 o AML (megakaryoblastic) with t(1 ;22)(p13;q13); RBM15-MKL1 o Provisional entity: AML with mutated NPM1

o Provisional entity: AML with mutated CEBPA

• Acute myeloid leukemia with myelodysplasia-related changes

• Therapy-related myeloid neoplasms

• Acute myeloid leukemia, not otherwise specified

o AML with minimal differentiation

o AML without maturation

o AML with maturation

o Acute myelomonocytic leukemia

o Acute monoblastic/monocytic leukemia

o Acute erythroid leukemia

^■ Pure erythroid leukemia

^■ Erythroleukemia, erythroid/myeloid

o Acute megakaryoblastic leukemia

o Acute basophilic leukemia

o Acute panmyelosis with myelofibrosis

• Myeloid sarcoma

• Myeloid proliferations related to Down syndrome

o Transient abnormal myelopoiesis

o Myeloid leukemia associated with Down syndrome

• Blastic plasmacytoid dendritic cell neoplasm In accordance with the present invention Bl 6727 may be administered by parenteral (e.g. intramuscular, intraperitoneal, intravenous, transdermal or subcutaneous injection), and may be formulated, alone or together, in suitable dosage unit formulations containing conventional non-toxic pharmaceutically acceptable carriers, adjuvants and vehicles appropriate for each route of administration. Dosage forms and formulations of both actives suitable within the present invention are known in the art. For instance, such dosage forms and formulations include those disclosed for Bl 6727 in WO 2006/018221 .

In accordance with the present invention Cytarabine may be administered by parenteral (e.g. intramuscular, intraperitoneal, intravenous, transdermal or

subcutaneous injection, or implant), routes of administration and may be formulated, alone or together, in suitable dosage unit formulations containing conventional nontoxic pharmaceutically acceptable carriers, adjuvants and vehicles appropriate for each route of administration.

The following Examples serve to illustrate the invention without restricting it:

Example: Clinical Trial

Methods:

Bl 6727 (350 mg) was administered as a one-hour intravenous infusion on Days 1 +15 every 28 days in combination with fixed dose LD-Ara-C (low-dose cytarabine) (20 mg twice daily s.c. [subcutaneous]). The starting dose of Bl 6727 was based on the MTD previously determined in solid tumor patients. Patients with no progression after the first cycle were allowed to continue treatment.

Results: Increasing Bl 6727 doses in combination with LD-Ara-C were evaluated in 32 patients (21 males, 1 1 females). Patient characteristics were as follows: median age 71 years (range 40-81 ); Eastern Cooperative Oncology Group performance score: 0: nine patients; 1 : 18 patients; 2: five patients. Safety: Drug-related adverse events (AEs) were reported in 18 of the 32 patients (56.3%). The most frequent drug- related AEs reported (>5%) were: anemia, diarrhea, febrile neutropenia and nausea which were 9.7% each), and decreased appetite, headache, mucositis and pain in extremity (each 6.5%). Dose-limiting toxicities (DLTs) were reported in four patients treated with Bl 6727+LD-Ara-C. DLTs as rated per protocol were: pneumonia, mucositis, hypersensitivity/allergic reaction and myocardial infarction. Based on the DLTs the MTD for Bl 6727 (d1 +15q28d) in combination with LD-Ara-C was determined to be 350 mg.

Efficacy: Preliminary best response data of 32 patients with relapsed/refractory AML treated at different Bl 6727 doses in combination with LD-Ara-C are available: seven patients achieved a incomplete blood count recovery (CRi) or complete remission (CR), 1 patients achieved a partial remission. Six patients had temporarily stable blood values ("no change" as best response). Eleven patients suffered from progression during or at the end of the first-treatment cycle, and seven patients had no response assessment (inedetermined).

Conclusions: Results indicate that Bl 6727 in combination with LD-Ara-C is well tolerated in patients with relapsed/refractory AML ineligible for intensive treatment. The MTD of Bl 6727 in combination with LD-Ara-C was determined at 350 mg. Bl 6727 in combination with LD-Ara-C showed first signs of clinical activity in AML patients.