阅读说明：本技术 治疗骨髓增生异常综合征的方法 (Methods of treating myelodysplastic syndrome ) 是由 A·里索 J·C·布索拉里 黄菲 于 2019-11-26 设计创作，主要内容包括：提供了在患有MDS的受试者中监测治疗疗效的方法。还提供了鉴定患有骨髓增生异常综合征(MDS)的受试者以用端粒酶抑制剂治疗的方法,和治疗MDS的方法。所述主题方法可以包含向所述受试者施用有效量的端粒酶抑制剂并评估从所述受试者获得的生物样品中的hTERT表达水平。在一些情况下,hTERT表达水平降低50％或更多鉴定了受益于用端粒酶抑制剂治疗的可能性增加的受试者。所述受试者可以未使用过HMA、来那度胺或两者进行治疗。在一些情况下,所述受试者被归类为患有低或中等1IPSS风险MDS和/或对红细胞生成刺激剂(ESA)复发性的/难治性的MDS。在一些情况下,端粒酶抑制剂为伊美司他钠。(Methods of monitoring the efficacy of a treatment in a subject with MDS are provided. Also provided are methods of identifying subjects having myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, and methods of treating MDS. The subject methods can comprise administering to the subject an effective amount of a telomerase inhibitor and assessing the level of hTERT expression in a biological sample obtained from the subject. In some cases, a 50% or more reduction in hTERT expression levels identifies a subject with an increased likelihood of benefit from treatment with a telomerase inhibitor. The subject may not have been treated with HMA, lenalidomide, or both. In some cases, the subject is classified as having low or moderate 1IPSS risk MDS and/or relapsed/refractory to Erythropoiesis Stimulating Agents (ESAs) MDS. In some cases, the telomerase inhibitor is sodium emedast.)

1. A method of identifying a subject having myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, the method comprising:

measuring the level of hTERT expression in a biological sample obtained from the subject after administration of a telomerase inhibitor; and

comparing the hTERT expression level in the biological sample to a baseline hTERT expression level prior to administration of the telomerase inhibitor;

wherein a decrease in the level of hTERT expression in the biological sample identifies a subject with an increased likelihood of benefit from treatment with the telomerase inhibitor.

2. The method of claim 1, wherein the reduction in the level of hTERT expression is 50% or more.

3. The method of any one of claims 1-2, wherein the subject is diagnosed with trisomy 8.

4. The method of claim 3, wherein the subject is diagnosed with a chimeric trisomy 8.

5. The method of any one of claims 3 to 4, further comprising diagnosing the subject with trisomy 8.

6. A method of treating myelodysplastic syndrome (MDS), comprising:

administering to a subject in need thereof an effective amount of a telomerase inhibitor; and

assessing the level of hTERT expression in a biological sample obtained from the subject after administration of the telomerase inhibitor.

7. The method of claim 6, wherein the hTERT expression level is reduced by 50% or more relative to a baseline hTERT expression level prior to administration of the telomerase inhibitor.

8. The method of claim 3 or 4, further comprising altering the dose, dosing frequency, or course of therapy administered to the subject of the telomerase inhibitor.

9. The method of any one of claims 6 to 8, wherein the subject is diagnosed with trisomy 8.

10. The method of claim 9, wherein the subject is diagnosed with a chimeric trisomy 8.

11. The method of any one of claims 9 to 10, further comprising diagnosing the subject with trisomy 8.

12. A method of monitoring therapeutic efficacy in a subject having myelodysplastic syndrome (MDS), comprising:

measuring the level of hTERT expression in a biological sample obtained from the subject after administration of a telomerase inhibitor; and

comparing the hTERT expression level in the biological sample to a baseline hTERT expression level prior to administration of the telomerase inhibitor;

wherein a 50% or more reduction in the level of hTERT expression in the biological sample identifies a subject with an increased likelihood of benefit from treatment with the telomerase inhibitor.

13. The method of any one of claims 1 to 12, wherein the hTERT expression level measured or assessed is an hTERT RNA expression level.

14. The method of any one of claims 1 to 12, wherein the hTERT expression level measured or assessed is an hTERT protein expression level.

15. The method of any one of claims 1-14, wherein the subject has not been treated with an agent selected from the group consisting of a hypomethylated agent (HMA), lenalidomide, and combinations thereof.

16. The method of any one of claims 1 to 15, wherein the MDS is relapsed or refractory MDS.

17. The method of any one of claims 1 to 16, wherein the MDS is relapsed/refractory to Erythropoiesis Stimulating Agents (ESAs).

18. The method according to any one of claims 1 to 17, wherein the subject is classified as a low or moderate 1IPSS risk MDS subject.

19. The method of any one of claims 1 to 18, wherein the subject is transfusion-dependent.

20. The method of claim 19, wherein said transfusion-dependent subject has a transfusion requirement of about 4 units or more during the 8 weeks prior to said administration of said telomerase inhibitor.

21. A method according to one of claims 1-20, wherein the subject is a non-del 5q human patient.

22. The method of any one of claims 1-21, wherein the subject has not been treated with lenalidomide.

23. The method of any one of claims 1 to 21, wherein the subject has not been treated with HMA selected from decitabine and azacitidine.

24. The method of any one of claims 1 to 23, wherein the telomerase inhibitor is eimestat.

25. The method of claim 24, wherein the exemestane is exemestane sodium.

26. The method of claim 24, wherein the telomerase inhibitor is emedasat and is administered for 1,2, 3, 4, 5, 6, 7,8, or more than 8 dosage cycles, each cycle comprising:

(a) about 7-10mg/kg of emedasat administered intravenously once every four weeks;

(b) intravenously administering about 7-10mg/kg of emedasat once a week for four weeks;

(c) about 2.5-10mg/kg of emedasat is administered intravenously once every three weeks; or

(d) About 0.5-9.4mg/kg of emedasat is administered intravenously every four weeks.

27. The method of claim 26, wherein each dosage cycle comprises intravenous administration of about 7-10mg/kg of emedasat once every four weeks.

28. The method of claim 1, wherein the MDS is relapsed or refractory MDS, and wherein the subject is classified as a low or moderate 1IPSS risk MDS subject.

29. The method of claim 28, wherein the subject is transfusion-dependent.

30. The method of claim 28, wherein the subject is a non-del 5q human patient.

31. The method of any one of claims 1-30, wherein the subject has not been treated with an agent selected from the group consisting of a hypomethylated agent (HMA) and lenalidomide.

32. The method of any one of claims 12 to 31, wherein the subject is diagnosed with trisomy 8.

33. The method of claim 32, wherein the subject is diagnosed with a chimeric trisomy 8.

34. The method of any one of claims 32 to 33, further comprising diagnosing the subject with trisomy 8.

35. A method of identifying a subject having myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, the method comprising: a subject diagnosed with trisomy 8.

36. A method of treating myelodysplastic syndrome (MDS), comprising:

administering an effective amount of a telomerase inhibitor to a subject in need thereof, wherein the subject is diagnosed with trisomy 8.

37. Use of a telomerase inhibitor in the treatment of a subject with myelodysplastic syndrome (MDS), wherein a decrease in hTERT expression level in a biological sample obtained from the subject after administration of the telomerase inhibitor is determined, as compared to a baseline hTERT expression level in a biological sample obtained from the subject before administration of the telomerase inhibitor.

38. Use of a telomerase inhibitor in the treatment of a subject with myelodysplastic syndrome (MDS), wherein the subject is diagnosed with trisomy 8.

Disclosure of Invention

Methods of monitoring the efficacy of a treatment in a subject with MDS are provided. Also provided are methods of identifying subjects having myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, and methods of treating MDS. The subject methods can comprise administering to the subject an effective amount of a telomerase inhibitor and assessing the level of hTERT expression in a biological sample obtained from the subject. In some cases, a 50% decrease or more in hTERT expression level identifies a subject with an increased likelihood of benefiting from treatment with a telomerase inhibitor. The subject may not have been treated with HMA, lenalidomide, or both. In some cases, the subject is classified as having low or moderate risk 1IPSS MDS and/or MDS that is relapsed/refractory to Erythropoiesis Stimulating Agents (ESAs). In some cases, the subject is non-del 5 q. In some cases, the telomerase inhibitor is emetastat or emetastat sodium.

Methods of treating MDS in a subject with a telomerase inhibitor are provided. The telomerase inhibitor is imatinib or imatinib sodium. The subject may not have been treated with HMA, lenalidomide, or both. In some cases, the subject is classified as having low or moderate risk 1IPSS MDS and/or MDS that is relapsed/refractory to Erythropoiesis Stimulating Agents (ESAs). In some cases, the subject is non-del 5 q. In some cases, the subject is classified as having moderate and poor cytogenetic risk for IPSS-R.

Drawings

The foregoing summary, as well as the following detailed description of the invention, will be better understood when read in conjunction with the appended drawings. For the purpose of illustrating the invention, the drawings show embodiments of the invention. It should be understood, however, that the invention is not limited to the precise arrangements, examples, and instrumentalities shown.

Figures 1A and 1B (first data cut-off) show the waterfall plot of the absolute change in blood volume (figure 1B) over the longest no-transfusion interval (figure 1A) and the optimal 8-week interval in the sodium imatinib study performed in Red Blood Cell (RBC) Transfusion Dependent (TD) patients as described in the experimental section herein. HI-E — hematology improvement-erythrocytes, increased at least 1.5g/dL over pretreatment levels for at least 8 weeks based on Hb, or decreased by at least 4 units of RBC infusion every 8 weeks compared to the previous RBC infusion burden (standard adapted from IWG 2006); HI-E Hb HI-E where hemoglobin continues to increase by at least 1.5g/dL within 8 weeks; TI is transfusion independent; TR-8 weeks transfusion decreased by at least 4 units.

Fig. 2 (first data cut-away) shows hematology and imatinib sodium administration timelines for an exemplary 24-week Transfusion Independent (TI) responder.

Figures 3A and 3B (second data shear plot) show a waterfall plot of the absolute change in blood volume (figure 3B) over the longest no transfusion interval (figure 3A) and the optimal 8 week interval in a study of sodium imatinib in Red Blood Cell (RBC) Transfusion Dependent (TD) patients as described in the experimental section herein. HI-E — hematologic improvement-erythrocytes, which increase the pretreatment level by at least 1.5g/dL over at least 8 weeks based on Hb, or decrease RBC infusion by at least 4 units every 8 weeks compared to the previous RBC infusion burden (standard adapted from IWG 2006); TI is transfusion independent; TR-8 weeks transfusion decreased by at least 4 units.

Figure 4 (second data shear) shows the therapeutic effect results in the EPO and RS subgroups.

Fig. 5 (second data shear) shows a hematology and imatinib sodium administration timeline for up to 115 weeks for an exemplary 24-week Transfusion Independent (TI) responder.

Figure 6 (second data shear graph) shows hemoglobin and emedastine sodium dosing in patients with persistent TI.

Figure 7 (fourth data shear) shows that the mean hTERT RNA expression level in patients decreased from baseline prior to treatment during study cycles 1 and 2.

Detailed Description

The present application provides methods of monitoring the efficacy of a treatment in a subject with MDS. Also provided are methods of identifying subjects having myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, and methods of treating MDS. The subject methods can comprise administering an effective amount of a telomerase inhibitor to a subject and assessing the level of hTERT expression in a biological sample obtained from the subject. In some cases, a 50% decrease or more in hTERT expression level identifies a subject with an increased likelihood of benefiting from treatment with a telomerase inhibitor. The subject may not have been treated with HMA, lenalidomide, or both. In some cases, the subject being treated is classified as having: low-IPSS-risk MDS, moderate-1 IPSS-risk MDS, MDS that is relapsing with Erythropoiesis Stimulating Agents (ESAs), MDS that is refractory to MS, or a combination thereof. The subject may not be del5 q. For clarity of disclosure, and not by way of limitation, the detailed description of the invention is divided into subsections that describe or illustrate certain features, embodiments, or applications of the invention. In some embodiments, the subject is diagnosed with trisomy 8.

A. Definition of

As used herein, the term "about," when referring to a measurable value such as an amount, time period, or the like, is meant to encompass variations from the stated value of ± 20% to ± 0.1%, preferably ± 20% or ± 10%, more preferably ± 5%, even more preferably ± 1%, and still more preferably ± 0.1%, as such variations are suitable for performing the disclosed methods.

The term "pharmaceutically acceptable salt" refers to a salt that is acceptable for administration to a patient, such as a mammal (for a given dosing regimen, a salt that contains a counterion that has acceptable mammalian safety). Such salts may be derived from pharmaceutically acceptable inorganic or organic bases and pharmaceutically acceptable inorganic or organic acids. "pharmaceutically acceptable salt" refers to pharmaceutically acceptable salts of compounds derived from a variety of organic and inorganic counterions well known in the art, and includes sodium and the like by way of example only; and salts of organic or inorganic acids, such as hydrochloride salts and the like, when the molecule contains a basic functional group. Pharmaceutically acceptable salts of interest include, but are not limited to, aluminum, ammonium, arginine, barium, benzathine, calcium, cholate, ethylenediamine, lysine, lithium, magnesium, meglumine, procaine, potassium, sodium, tromethamine, N-methylglucamine, N' -dibenzylethylenediamine, chloroprocaine, diethanolamine, ethanolamine, piperazine, zinc, diisopropylamine, diisopropylethylamine, triethylamine, and triethanolamine.

The term "salt thereof" refers to a compound formed when the proton of an acid is substituted with a cation such as a metal cation or an organic cation, etc. Preferably, the salt is a pharmaceutically acceptable salt. For example, salts of the compounds of the present invention include those in which the compound is protonated by an inorganic or organic acid to form a cation, with the conjugate base of the inorganic or organic acid as the anionic component of the salt. Salts of interest include, but are not limited to, aluminum, ammonium, arginine, barium, benzathine, calcium, cesium, cholate, ethylenediamine, lithium, magnesium, meglumine, procaine, N-methylglucamine, piperazine, potassium, sodium, tromethamine, zinc, N' -dibenzylethylenediamine, chloroprocaine, diethanolamine, ethanolamine, piperazine, diisopropylamine, diisopropylethylamine, triethylamine, and triethanolamine. It will be appreciated that for any oligonucleotide structure comprising a backbone of internucleoside linkages (internucleoside linkages) as described herein, such oligonucleotides may also comprise any convenient salt form. In some embodiments, for simplicity, the acidic form of the internucleoside linkage is described. In some cases, a salt of the subject compound is a monovalent cation salt. In certain instances, a salt of the subject compound is a divalent cation salt. In some cases, a salt of the subject compound is a salt of a trivalent cation. "solvate" refers to a complex formed by the binding of a solvent molecule to a molecule or ion of a solute. The solvent may be an organic compound, an inorganic compound, or a mixture of both. Some examples of solvents include, but are not limited to, methanol, N-dimethylformamide, tetrahydrofuran, dimethylsulfoxide, and water. When the solvent is water, the solvate formed is a hydrate.

"stereoisomers (sterosomers)" and "stereoisomers (sterosomers)" refer to compounds that have the same atomic connectivity in space but differ in atomic arrangement. Stereoisomers include, for example, cis and trans isomers, E and Z isomers, enantiomers and diastereomers. With respect to any group disclosed herein that contains one or more substituents, it is, of course, understood that such groups do not contain any sterically impractical and/or synthetically non-feasible substitution or substitution patterns. All stereoisomers are intended to be included within the scope of the present disclosure.

One of ordinary skill in the art will recognize that other tautomeric arrangements of the groups described herein are possible. It is to be understood that all tautomeric forms of the subject compounds are encompassed by the structure wherein one possible tautomeric arrangement of the radical of the compound is depicted, even if not specifically stated.

Solvates of pharmaceutically acceptable salts of tautomers that are intended to comprise stereoisomers of the subject compounds. These are intended to be included within the scope of the present disclosure.

Before certain embodiments are described in greater detail, it is to be understood that this invention is not limited to certain described embodiments, as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the present invention will be limited only by the appended claims.

Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limit of that range and any other stated or intervening value in that stated range is encompassed within the invention. The upper and lower limits of these smaller ranges may independently be included in the smaller ranges, and are also encompassed within the invention, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the invention.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Representative illustrative methods and materials are now described, although any methods and materials similar or equivalent to those described herein can also be used in the practice or testing of the present invention.

All publications and patents cited in this specification are herein incorporated by reference as if each individual publication or patent were specifically and individually indicated to be incorporated by reference and were incorporated by reference to disclose and describe the methods and/or materials in connection with which the publications were cited. The citation of any publication is for its disclosure prior to the filing date and should not be construed as an admission that the present invention is not entitled to antedate such publication by virtue of prior invention. Furthermore, the dates of publication provided may be different from the actual publication dates, which may require independent confirmation.

It should be noted that, as used herein and in the appended claims, the singular forms "a," "an," and "the" include plural referents unless the context clearly dictates otherwise. It is further noted that the claims may be drafted to exclude any optional element. Accordingly, the statements are intended to serve as antecedent basis for use of such exclusive terminology as "solely," "only," and the like in connection with the recitation of claim elements or use of a "negative" limitation.

Each of the individual embodiments described and illustrated herein has discrete components and features that may be readily separated from or combined with the features of any of the other several embodiments without departing from the scope or spirit of the present invention. Any recited method may be implemented in the order of the recited events or in any other order that is logically possible.

As used throughout, "MDS" refers to myelodysplastic syndrome (myelodysplastic syndrome) or myelodysplastic syndromes.

B. Pharmacodynamics (PD)

The present disclosure is based, in part, on a pharmacodynamic effect that demonstrates an association between a response to telomerase inhibitory therapy in a subject with MDS and a decrease in telomerase hTERT expression level in the subject from a baseline level. For example, in the clinical study described herein, a higher percentage of subjects achieved a 50% or greater reduction in hTERT RNA expression levels in 8-week Transfusion Independent (TI) responders than in non-responders.

The present disclosure provides for the stratification and identification or selection of patients who may benefit from telomerase inhibitory therapy for MDS, and provides methods of monitoring response, recurrence and prognosis in subjects undergoing treatment.

Aspects of the disclosure include methods of identifying or selecting subjects having myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, and methods of treating MDS. Also provided are methods of monitoring the efficacy of a treatment in a subject with MDS. In some cases, embodiments of the subject methods are based on a pharmacodynamic effect that is a 50% or greater reduction in hTERT RNA expression, such as 60% or greater, 70% or greater, 80% or greater, or 90% or greater.

Telomerase ribonucleoprotein consists of components or subunits, two of which are telomerase RNA template (hTR), and telomerase reverse transcriptase protein (hTERT). Any convenient method can be used to assess, determine and/or measure hTERT expression levels. Various methods can be used to amplify, detect and measure mRNA of telomerase components or related proteins in body fluids. Methods and assays of interest that may be suitable for use in the subject methods include, but are not limited to, real-time quantitative RT-PCR assays, such as TaqMan-based fluorescence methods; immunohistochemical methods for protein expression and methods described by, U.S. Pat. No. 6,607,898, Bieche et al, clinical cancer research 2000, 2.1.1 (6) (2)452 & 459, Terrin et al ("Telomerase expression in B-cell chronic lymphocytic leukemia predicts survival and can demarcate groups of patients with identical igVH mutation status and different outcomes (Terrase expression in B-cell transcriptional differentiation outer genome)," leukemia with the same sampling VH mutation status 2007; 20121: 965 & 972) and Palma et al ("human Telomerase reverse transcriptase length and expression variant in chronic lymphocytic leukemia" (Telecommerce 22 & 626), blood sample length and expression of protein transcript).

The expression level of hTERT can be assessed or measured in any convenient target cell. The target cell may be any convenient cell of the patient, including but not limited to a cell of the bone marrow or peripheral blood of the patient. In some cases, the target cells are isolated from a bone marrow sample of the patient. In some cases, the target cells are isolated from a peripheral blood sample of the patient. The target cell may be a granulocyte.

Any convenient method can be used to assess or measure the level of hTERT RNA expression in an RNA sample. The RNA sample can be obtained by: the method includes the steps of first obtaining a bone marrow sample, a peripheral blood sample, or both, and then isolating RNA from the bone marrow sample, the peripheral blood sample, or both. In one embodiment, the step of obtaining a sample from a patient comprises: obtaining a bone marrow sample from a patient, isolating cells from the bone marrow sample, and extracting RNA and/or DNA from the isolated cells. In another embodiment, the step of obtaining an RNA sample from a patient comprises: obtaining a peripheral blood sample from a patient; isolating cells (e.g., granulocytes) from a peripheral blood sample; and extracting RNA and/or DNA from the isolated cells.

C. Treatment of

Aspects of the present disclosure include methods of treating myelodysplastic syndrome (MDS) with a telomerase inhibitor in a subject who has not been treated with a specific agent, e.g., an agent selected from the group consisting of hypomethylated agents (HMA) and lenalidomide. A subject is considered "untreated" if the subject has not undergone a particular treatment for the disease. Treatment of patients with MDS that is relapsed/refractory to ESA therapy with emedast may improve outcomes, including lower incidence of anemia.

The subject is a mammal in need of cancer treatment. Typically, the subject is a human patient. In some embodiments of the invention, the subject may be a non-human mammal, such as a non-human primate, animal models (e.g., animals used to screen, characterize, and evaluate drugs, such as mice and rats), and other mammals. As used herein, the terms patient, subject, and individual are used interchangeably.

As used herein and as is well known in the art, "treatment" is a method for obtaining beneficial or desired results, including clinical results. For purposes of the present invention, beneficial or desired clinical results include, but are not limited to, alleviation or amelioration of one or more symptoms, diminishment of extent of disease, stabilization (i.e., not worsening) of the state of the disease, prevention of spread of disease, delay or slowing of disease progression, amelioration or palliation of the disease state, and remission (whether partial or total), whether detectable or undetectable. "treatment" may also refer to an increase in survival compared to the expected survival if not treated.

In certain instances, the subject methods provide enhanced therapeutic response relative to previously so treated subjects in those subjects that have not previously been treated with hypomethylating agents (HMA) or lenalidomide. By "enhanced therapeutic response" is meant a statistically significant improvement in the primary and/or secondary endpoints of MDS therapy and/or an improvement in one or more symptoms of MDS (e.g., as described herein), e.g., the rate and/or duration of Red Blood Cell (RBC) transfusion-dependent (TI), or the rate of Hematologic Improvement (HI), relative to an appropriate control. In some cases, the subject methods provide a therapeutic effect of Red Blood Cell (RBC) transfusion-dependent (TI), e.g., for 4 weeks or more, such as 5 weeks or more, 6 weeks or more, 7 weeks or more, 8 weeks or more, 9 weeks or more, 10 weeks or more, 12 weeks or more, 16 weeks or more, 20 weeks or more, 24 weeks or even more. In some cases, the time to reach TI and/or the duration of TI improves significantly. In certain instances, the subject methods provide a TI duration of 24 weeks or longer, such as 30 weeks or longer, 36 weeks or longer, 42 weeks or longer, 48 weeks or longer, 60 weeks or longer, or even longer.

Hypomethylating agents (HMA) are agents that inhibit DNA methylation, for example by blocking the activity of DNA methyltransferases (DNA methyltransferase inhibitors/DNMT inhibitors). HMAs of interest include, but are not limited to, decitabine (CAS registry number: 2353-33-5; 5-aza-2' -deoxycytidine), azacitidine (CAS registry number: 320-67-2, 5-azacitidine), and guadecitabine (SGI-110). In some cases, the subject is not treated with decitabine. In some cases, the subject has not been treated with azacitidine. In other cases, the subject is not treated with decitabine and azacitidine.

Lenalidomide is a drug used in the treatment of a variety of inflammatory disorders and cancers, including multiple myeloma and MDS. Lenalidomide (CAS registry No.: 191732-72-6; 2, 6-piperidinedione, 3- (4-amino-1, 3-dihydro-1-oxo-2H-isoindol-2-yl) -); 3- (4-amino-1-oxoisoindolin-2-yl) piperidine-2, 6-dione) is a derivative of thalidomide. Lenalidomide has multiple mechanisms of action that provide a wide range of biological activities that can be used to treat a variety of hematological and solid cancers.

Deletion 5q (del5q) refers to chromosomal abnormalities found in subjects with particular forms of MDS (Adema et al, hematology 2013, 12 months; 98(12): 1819-. In some cases of the subject methods, the subject is a human patient with del5 q. In some cases, the subject is a non-del 5q human patient. Non-del 5q subjects are subjects without del5q chromosomal abnormalities. In certain instances, a non-del 5q subject is a human.

In certain instances, the subject has not received prior treatment with hypomethylating agent (HMA) or lenalidomide and has no del (5q) chromosomal abnormality (e.g., is not del5 q). In certain instances, a non-del 5q subject is a human.

In certain embodiments, the subject is a human patient with a moderate or poor cytogenetic risk. In some cases, the subject is a human patient diagnosed as having trisomy 8. In certain instances, the subject is a human patient with chimeric trisomy 8. In other cases, the subject is a human patient with a chimeric-free trisomy 8. The term "chimerism" is used herein in its conventional sense to refer to a condition in which cells within a subject have a different genetic composition. In a human patient diagnosed with chimeric trisomy 8, some cells of the subject have three copies of chromosome 8, while other cells have two copies of chromosome 8.

In certain embodiments, the method comprises identifying a subject with myelodysplastic syndrome (MDS) for treatment with a telomerase inhibitor, wherein the method comprises: identifying a subject having trisomy 8 (with or without chimerism); measuring the level of hTERT expression in a biological sample obtained from the patient after administration of the telomerase inhibitor; and comparing the hTERT expression level in the biological sample to a baseline hTERT expression level prior to administration of the telomerase inhibitor; wherein a decrease in the level of hTERT expression in the biological sample identifies a patient with an increased likelihood of benefit from treatment with the telomerase inhibitor.

In other embodiments, the method comprises treating myelodysplastic syndrome (MDS) in a subject diagnosed as having trisomy 8, wherein the method comprises: identifying a subject diagnosed as having trisomy 8; administering to the subject an effective amount of a telomerase inhibitor; and assessing the level of hTERT expression in a biological sample obtained from the patient after administration of the telomerase inhibitor.

In still other embodiments, a method comprises monitoring the efficacy of a treatment in a subject having myelodysplastic syndrome (MDS), wherein the method comprises: measuring the level of hTERT expression in a biological sample obtained from a patient diagnosed with trisomy 8 after administration of a telomerase inhibitor; and comparing the hTERT expression level in the biological sample to a baseline hTERT expression level prior to administration of the telomerase inhibitor; wherein a 50% or more reduction in the level of hTERT expression in the biological sample identifies a subject with an increased likelihood of benefit from treatment with the telomerase inhibitor.

In the method according to certain embodiments, the subject is a patient diagnosed as having trisomy 8. In other embodiments, the subject is a patient diagnosed with trisomy 8 and has not been treated with an agent selected from the group consisting of hypomethylated agents (HMA), lenalidomide, and combinations thereof. In other embodiments, the subject is a patient diagnosed with trisomy 8 and is a non-del 5q human patient. In yet other embodiments, the subject is a patient diagnosed with trisomy 8, and the MDS is relapsed or refractory MDS, such as relapsed/refractory MDS to Erythropoiesis Stimulating Agents (ESAs).

D.Myelodysplastic syndrome (MDS)

Myelodysplastic syndrome ("MDS") is a group of diseases that include cancers of the blood and bone marrow, and in some cases may be characterized by cytopenia caused by ineffective hematopoiesis. A variety of MDSs can be treated using the subject methods, including, but not limited to, diseases such as refractory anemia, refractory anemia with hyperproliferation of primordial cells, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, chronic myelomonocytic leukemia, MDS with isolated del (5q), and unclassifiable MDS.

MDS is characterized by clonal myeloid proliferation resulting from malignant progenitor cell clones with shorter telomeres and multiple clonal genetic abnormalities. Telomerase Activity (TA) and expression of human telomerase reverse transcriptase (hTERT) are significantly increased in MDS and can play a role in cell growth dysregulation, resulting in sustained and uncontrolled proliferation of malignant progenitor cell clones. Higher TA and hTERT, and shorter telomere length are poor prognostic characteristics in patients with low risk MDS, leading to shorter overall survival. For anemia of lower risk MDS that recurs after ESA therapy or is refractory to ESA therapy, treatment options are limited. The use of imatinib-targeted MDS clones can improve outcomes, including anemia, in patients with MDS that is relapsed/refractory to ESA therapy.

In some embodiments, the subject methods find use in alleviating at least one symptom associated with myelodysplastic syndrome, such as, for example, refractory anemia with hyperplastic cells, refractory cytopenia with multilineage dysplasia, and chronic myelomonocytic leukemia. In some embodiments, the symptom comprises shortness of breath, fatigue, weakness, syncope, bleeding from the nose, bruising, bleeding from the mouth or gums, bloody stools, petechiae, or stroke.

In some cases, the subject has relapsed or refractory MDS. "refractory MDS" refers to a patient who has MDS cells in their bone marrow after treatment with any convenient MDS-related therapy. "relapsed MDS" refers to a patient whose MDS cells recover in their bone marrow and normal blood cells are reduced after remission. In certain instances, the subject has MDS that is relapsed/refractory to Erythropoiesis Stimulating Agents (ESAs). In some cases of MDS, ESA can raise hemoglobin levels and eliminate transfusion dependence over time. ESAs of interest include, but are not limited to, erythropoietin alpha, erythropoietin beta, and darbepoetin.

In some embodiments, the subject is identified as a human patient with trisomy 8. In certain instances, the subject is a human patient with chimeric trisomy 8. In other cases, the subject is a human patient with a chimeric-free trisomy 8.

In certain embodiments of the subject methods, the subject is classified as a low or moderate 1IPSS risk MDS subject. Myelodysplastic syndrome (MDS) patients can be classified into lower risk groups (low and medium 1[ INT-1] IPSS) in which apoptotic events in the bone marrow are prevalent and responses to cytokines, including erythropoietin, are defective; and higher risk groups (intermediate 2[ INT-2] and high IPSS), in which arrest of maturation of bone marrow progenitors is the major change. In some cases, transfusion dependence is a negative prognostic variable. Thus, in certain embodiments of the methods, the subject is Red Blood Cell (RBC) transfusion-dependent. In some cases, the transfusion-dependent subject has a RBC transfusion requirement of about 4 units or more within 8 weeks; or 4-14 units over an 8 week period, or about 6 units or more every 8 weeks prior to administration according to the subject methods. The unit of concentrated red blood cells (PRBC) may be about 300 mL/unit. The unit of whole blood may be about 450 and 500 mL/unit.

The International Prognostic Scoring System (IPSS) is a system developed for staging MDS. There are 3 factors for IPSS rate: the percentage of leukemic blasts in bone marrow cells (scored according to a 0 to 2 scale); chromosomal abnormalities (if any) in bone marrow cells (scoring from 0 to 1); and the presence of one or more low blood counts (score 0 or 0.5). Each factor gives a score, with the lowest score having the best prospects. The scores for these factors are then added to arrive at the IPSS score. IPSS divided the people with MDS into 4 groups: a low risk group; moderate 1 risk; medium 2 risk; and high risk.

E.Telomerase inhibitors

Any convenient telomerase inhibitor may find use in the subject methods. In some embodiments, the telomerase inhibitor is an oligonucleotide having telomerase inhibitory activity, in particular an oligonucleotide as defined in WO 2005/023994 and/or WO 2014/088785 (the disclosures of which are incorporated herein by reference in their entirety). In some cases, one or more than one telomerase inhibitor (e.g., two or three telomerase inhibitors) can be administered to a mammal to treat a hematologic malignancy.

Emeistat

In certain embodiments, the telomerase inhibitor is eimetat, including tautomers thereof and salts, e.g., pharmaceutically acceptable salts, thereof. Imestat is a novel and superior telomerase inhibitor with clinical activity in hematological malignancies (Baerlocher et al, New England Journal of Medicine (NEJM) 2015; 373: 920-:

where "nps" represents the phosphorothioate amide linkage-NH-P (═ O) (SH) -O-which links the 3 '-carbon of one nucleoside to the 5' -carbon of the adjacent nucleoside.

In some cases, the telomerase inhibitor is sodium emedast, including tautomers thereof. Imatinib sodium is the sodium salt of imatinib, a synthetic lipid-conjugated 13-mer oligonucleotide N3'→ P5' -thiophosphoramide. Imatinib sodium is a telomerase inhibitor, a covalently lipidated 13-mer oligonucleotide (shown below) complementary to the human telomerase rna (htr) template region. The chemical name of the sodium isometate is as follows: DNA, d (3 ' -amino-3 ' -deoxy-P-thio) (T-A-G-G-G-T-T-A-G-A-C-A-A), 5' - [ O- [ 2-hydroxy-3- (h mut mutexadecanoylamino) propyl ] thiophosphoric acid) sodium salt (1:13) (SEQ ID NO: 1). Imatinib sodium does not act via an antisense mechanism and, therefore, has no side effects commonly observed in such therapies.

Unless otherwise indicated or clear from the context, the reference to isometastat herein also includes tautomers thereof and salts thereof, e.g., pharmaceutically acceptable salts. As mentioned before, especially the sodium imatinib is the sodium salt of imatinib. Unless otherwise indicated or clear from the context, reference herein to sodium isometate also includes all tautomers thereof.

As described elsewhere, imatinib and imatinib sodium may be produced, formulated or obtained (see, e.g., Asai et al, cancer research 63: 3931-. Unless otherwise indicated or clear from the context, reference herein to exemestane also encompasses salts thereof. As mentioned before, especially the sodium imatinib is the sodium salt of imatinib.

In various cancer cell lines and tumor xenografts in mice, imatstat targeted the RNA template of telomerase and inhibited telomerase activity-malignant cell proliferation. Phase 1 studies involving patients with breast cancer, non-small cell lung cancer and other solid tumors, multiple myeloma or chronic lymphocytic leukemia provide pharmacokinetic and pharmacodynamic information. Subsequent phase 2 studies involving patients with primary thrombocythemia showed that the thrombocytopenic activity was accompanied by a significant reduction in the allele burden of the JAK 2V 617F and CALR mutations. Daily intravenous administration of emedast sodium. It is contemplated that other routes of administration, such as intrathecal administration, intratumoral injection, oral administration, and the like, may also be used in the practice of the subject methods. The emedastine sodium may be administered in a dose comparable to that conventionally used in the clinic. In certain embodiments, the emedastine sodium is administered as described elsewhere herein.

A particular embodiment is according to any one of the other embodiments, wherein the emedast is limited to emedastine sodium.

F. Pharmaceutical composition

For ease of administration, telomerase inhibitors (e.g., as described herein) can be formulated into various pharmaceutical forms for administration purposes. In some cases, the telomerase inhibitor is administered as a pharmaceutical composition. The carrier or diluent for a pharmaceutical composition must be "acceptable" in the sense of being compatible with the other ingredients of the composition and not deleterious to the recipient thereof. The pharmaceutical compositions may be in unit dosage form, which is particularly suitable for oral, rectal, transdermal, administration by parenteral injection or administration by inhalation. In some cases, administration may be by intravenous injection. For example, in preparing the compositions in oral dosage form, any of the usual pharmaceutical media may be employed, such as, for example, water, glycols, oils, alcohols and the like (in the case of oral liquid preparations such as suspensions, syrups, elixirs, emulsions and solutions); or solid carriers such as starches, sugars, kaolin, diluents, lubricants, binders, disintegrating agents and the like (in the case of powders, pills, capsules and tablets). Because of their ease of administration, tablets and capsules represent the most advantageous oral dosage unit form in which case solid pharmaceutical carriers are obviously employed. For parenteral compositions, the carrier will typically comprise sterile water, at least in large part, although other ingredients, for example to aid solubility, may also be included. For example, injectable solutions may be prepared in which the carrier comprises saline solution, glucose solution or a mixture of saline and glucose solution. For example, injectable solutions may be prepared in which the carrier comprises saline solution, glucose solution or a mixture of saline and glucose solution. Injectable solutions containing the telomerase inhibitor described herein may be formulated in oil for prolonged action. Suitable oils for this purpose are, for example, peanut oil, sesame oil, cottonseed oil, corn oil, soybean oil, synthetic glycerol esters of long-chain fatty acids, and mixtures of these and other oils. Injectable suspensions may also be prepared in which case appropriate liquid carriers, suspending agents and the like may be employed. In addition, solid form preparations are also included, which are intended to be converted, shortly before use, to liquid form preparations. In compositions suitable for transdermal application, the carrier optionally includes a penetration enhancer and/or a suitable wetting agent, optionally in combination with suitable additives of any nature, in minor proportions, which additives do not produce a significant deleterious effect on the skin. The additives may facilitate application to the skin and/or may aid in the preparation of the desired composition. The compositions may be administered in various ways, for example as a transdermal patch, as a spot-on, as an ointment.

It is particularly advantageous to formulate the above pharmaceutical compositions in unit dosage form for ease of administration and uniformity of dosage. Unit dosage form as used herein refers to physically discrete units suitable as unitary dosages, each unit containing a predetermined quantity of active ingredient calculated to produce the desired therapeutic effect in association with the required pharmaceutical carrier. Examples of such unit dosage forms are tablets (including scored or coated tablets), capsules, pills, powder packets, implants (wafers), suppositories, injectable solutions or suspensions and the like and isolated multiple forms thereof.

In order to improve the solubility and/or stability of the drugs described herein in the pharmaceutical composition, it may be advantageous to use alpha-, beta-or gamma-cyclodextrins or derivatives thereof, in particular hydroxyalkyl-substituted cyclodextrins, such as 2-hydroxypropyl-beta-cyclodextrin or sulfobutyl-beta-cyclodextrin. Furthermore, co-solvents such as alcohols may improve the solubility and/or stability of telomerase inhibitors in pharmaceutical compositions.

Depending on the mode of administration, the pharmaceutical composition will preferably comprise 0.05 to 99 wt.%, more preferably 0.1 to 70 wt.%, even more preferably 0.1 to 50 wt.% of a telomerase inhibitor as described herein, and 1 to 99.95 wt.%, more preferably 30 to 99.9 wt.%, even more preferably 50 to 99.9 wt.% of a pharmaceutically acceptable carrier, all percentages being based on the total weight of the composition.

G.Administration and administration regimens

The frequency of administration can be any frequency that reduces the severity of a symptom of MDS (e.g., as described herein) without producing significant toxicity in the subject. For example, the frequency of administration may be about once every two months to about once a week, alternatively about once a month to about twice a month, alternatively about once every six weeks, about once every 5 weeks, alternatively about once every 4 weeks, alternatively about once every 3 weeks, alternatively about once every 2 weeks or alternatively about once a week. The frequency of administration may remain constant or may be variable during the duration of the treatment. A course of treatment with a composition containing one or more telomerase inhibitors may include a rest period. For example, a composition containing a telomerase inhibitor may be administered weekly over a three week period, followed by a two week rest period, and this regimen may be repeated multiple times. As with the effective amount, various factors can affect the actual frequency of administration for a particular application. For example, an effective amount, duration of treatment, use of multiple therapeutic agents, route of administration, and severity of MDS and associated symptoms may require an increase or decrease in frequency of administration.

The effective duration of administration of a composition containing a telomerase inhibitor (e.g., eimostat or sodium eimostat) can be any duration that alleviates the severity of symptoms of MDS (e.g., as described herein) without producing significant toxicity to the subject. Thus, the effective duration may vary from one month to several months or years (e.g., one month to two years, one month to one year, three months to two years, three months to ten months, or three months to 18 months). In general, an effective duration of treatment for MDS can range from a duration of two months to twenty months. In some cases, the effective duration may be the time that the individual subject survives. Various factors may affect the actual effective duration for a particular treatment. For example, the duration of effectiveness can vary with the frequency of administration, the effective amount, the use of various therapeutic agents, the route of administration, and the severity of the MDS and associated symptoms.

In some cases, the progress of treatment, as well as the severity of one or more symptoms associated with MDS, can be monitored. Any method may be used to determine whether a symptom of MDS is reduced in severity. For example, biopsy techniques can be used to assess the severity of symptoms of MDS (e.g., as described herein).

Telomerase inhibitors as used in the subject methods may be administered at any therapeutically effective dose, such as a dose comparable to that routinely used clinically. Specific dosage regimens (e.g., recommended effective doses) of known and approved anti-cancer agents are known to PHYSICIANS, and are described, for example, in physician's desk reference (physcians' DESK REFERENCE) 2003, 57 th edition, Medical economies Company, Inc., Oradell, n.j., nj; goodman & Gilman, 2001, 10 th edition, McGraw-Hill, N.Y., product description found in THE PHARMACOLOGICAL BASIS OF THERAPEUTICS (THE PHARMACOGICAL BASIS OF THERAPEUTIC); and/or may be obtained from the Federal Drug Administration (Federal Drug Administration) and/or discussed in the medical literature.

In some aspects, the telomerase inhibitor is administered to the subject in a dose of about 1.0mg/kg to about 13.0mg/kg of emetas sodium. In other aspects, the telomerase inhibitor is administered at a dose of about 4.5mg/kg to about 11.7mg/kg or about 6.0mg/kg to about 11.7mg/kg or about 6.5mg/kg to about 11.7 mg/kg. In some embodiments, the dose of telomerase inhibitor comprises at least about any of the following: 4.7mg/kg, 4.8mg/kg, 4.9mg/kg, 5.0mg/kg, 5.5mg/kg, 6.0mg/kg, 6.1mg/kg, 6.2mg/kg, 6.3mg/kg, 6.4mg/kg, 6.5mg/kg, 6.6mg/kg, 6.7mg/kg, 6.8mg/kg, 6.9mg/kg, 7mg/kg, 7.1mg/kg, 7.2mg/kg, 7.3mg/kg, 7.4mg/kg, 7.5mg/kg, 7.6mg/kg, 7.7mg/kg, 7.8mg/kg, 7.9mg/kg, 8mg/kg, 8.1mg/kg, 8.2mg/kg, 8.3mg/kg, 8.4mg/kg, 8.5mg/kg, 8.6mg/kg, 8.9mg/kg, 8.1mg/kg, 8.2mg/kg, 8.3mg/kg, 8.4mg/kg, 8.5mg/kg, 8.6mg/kg, 8.9mg/kg, 9mg/kg, 9.9mg/kg, 9mg/kg, 9.9mg/kg, 9mg/kg, 6.9mg/kg, 6.6mg/kg, 6 mg/1 mg/kg, 6.6.6 mg/kg, 6.6mg/kg, 6mg/kg, 6.6.6 mg/kg, 6.6 mg/6.6.6 mg/6 mg/kg, 6 mg/6.6 mg/kg, 6 mg/6.6 mg/kg, 6.6 mg/6 mg/kg, 6.6mg/kg, 6mg/kg, 6mg/kg, 6.6mg/kg, 6mg/kg, 6.6mg/kg, 6mg/kg, 6.6 mg/6 mg/kg, 6.6.6.6.6.6.6.6 mg/6 mg/kg, 6 mg/6.6.6.6.6.6.6.6.6.6 mg/6.6.6 mg/kg, 6.6 mg/6.6.6 mg/kg, 6mg/kg, 6.6mg/kg, 9.2mg/kg, 9.3mg/kg, 9.4mg/kg, 9.5mg/kg, 9.6mg/kg, 9.7mg/kg, 9.8mg/kg, 9.9mg/kg, 10mg/kg, 10.1mg/kg, 10.2mg/kg, 10.3mg/kg, 10.4mg/kg, 10.5mg/kg, 10.6mg/kg, 10.7mg/kg, 10.8mg/kg, 10.9mg/kg, 11mg/kg, 11.1mg/kg, 11.2mg/kg, 11.3mg/kg, 11.4mg/kg, 11.5mg/kg, 11.6mg/kg, 11.7mg/kg, 11.8mg/kg, 11.9mg/kg, 12mg/kg, 12.1mg/kg, 12.2mg/kg, 12.3mg/kg, 12.4mg/kg, 12.5mg/kg, 12.6mg/kg, 12.7mg/kg, 12.8mg/kg, 12.9mg/kg, 12.6mg/kg, 12.1mg/kg, 8mg/kg, 10.2mg/kg, 10.6mg/kg, 10.3mg/kg, 10.6mg/kg, 10.1mg/kg, 10.4mg/kg, 10.6mg/kg, 10.1mg/kg, 10.4mg/kg, 10.4mg/kg, 10.6mg/kg, 10.1mg/kg, 10.6mg/kg, 10.6mg/kg, 10.1mg/kg, 10.6mg/kg, 10.6mg/kg, 10.6mg/kg, 10.6mg/kg, 10.6mg/kg, 10.6mg/kg, 10.1mg/, 12.9mg/kg or 13 mg/kg.

In some embodiments, the effective amount of telomerase inhibitor administered to the individual comprises at least about any of 1mg/kg, 2.5mg/kg, 3.5mg/kg, 4.7mg/kg, 5mg/kg, 6.0mg/kg, 6.5mg/kg, 7.5mg/kg, 9.4mg/kg, 10mg/kg, 15mg/kg, or 20 mg/kg. In some embodiments, the effective amount of telomerase inhibitor administered to the individual is any of about 1mg/kg, 2.5mg/kg, 3.5mg/kg, 5mg/kg, 6.5mg/kg, 7.5mg/kg, 9.4mg/kg, 10mg/kg, 15mg/kg, or 20 mg/kg. In various embodiments, an effective amount of a telomerase inhibitor administered to a subject comprises less than about any of 350mg/kg, 300mg/kg, 250mg/kg, 200mg/kg, 150mg/kg, 100mg/kg, 50mg/kg, 30mg/kg, 25mg/kg, 20mg/kg, 10mg/kg, 7.5mg/kg, 6.5mg/kg, 5mg/kg, 3.5mg/kg, 2.5mg/kg, 1mg/kg, or 0.5mg/kg of a telomerase inhibitor.

Exemplary administration frequencies of a pharmaceutical composition comprising a telomerase inhibitor include, but are not limited to, daily; every other day; twice a week; three times per week; continuously in each week; weekly, three out of four weeks; once every three weeks; once every two weeks; once a week, two out of three weeks. In some embodiments, the pharmaceutical composition is administered about once a week, once every 2 weeks, once every 3 weeks, once every 4 weeks, once every 5 weeks, once every 6 weeks, once every 7 weeks, or once every 8 weeks. In some embodiments, the composition is administered at least about any one of 1x, 2x, 3x, 4x, 5x, 6x, or 7x weekly (i.e., daily), or three times daily, twice daily. In some embodiments, the interval between each administration is less than any of about 6 months, 3 months, 1 month, 20 days, 15 days, 12 days, 10 days, 9 days, 8 days, 7 days, 6 days, 5 days, 4 days, 3 days, 2 days, or 1 day. In some embodiments, the interval between each administration is greater than any one of about 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 8 months, or 12 months. In some embodiments, there is no interruption in the dosing schedule. In some embodiments, the interval between each administration is no more than about one week.

Any suitable method may be used to administer the telomerase inhibitor, such as imatinib (e.g., sodium imatinib). For example, a telomerase inhibitor such as exemestane (e.g., exemestane sodium) can be administered intravenously once every 4 weeks over a period of time (e.g., one, two, three, four, or five hours). In some embodiments, imatinib is administered intravenously at 7-10mg/kg once weekly over a period of about 2 hours. In certain embodiments, the imatinib is administered intravenously at 2.5-7mg/kg once every 3 weeks over a period of about 2 hours. In one embodiment, the imatinib is administered intravenously at 0.5-5mg/kg once every 4 weeks over a period of about 2 hours. In one embodiment, the imatinib is administered intravenously at about 2.5-10mg/kg once every 3 weeks over a period of about 2 hours. Alternatively, imatinib is administered intravenously at about 0.5-9.4mg/kg once every 4 weeks over a period of about 2 hours.

In certain embodiments of the method, the emedastine is administered for 1,2, 3, 4, 5, 6, 7,8, or more than 8 dosage cycles, each cycle comprising: about 7-10mg/kg of emedasat intravenously once every four weeks, about 7-10mg/kg of emedasat intravenously once a week for four weeks, about 2.5-10mg/kg of emedasat intravenously once every three weeks, or about 0.5-9.4mg/kg of emedasat once every four weeks. In some cases, each dosage cycle comprises intravenous administration of about 7-10mg/kg of emedasat once every four weeks. In some cases, each administration cycle comprises intravenous administration of about 7.5mg/kg of emedasat about once every four weeks.

In one embodiment of the invention, after pre-operative administration with an antihistamine, a corticosteroid, or both, the emedasat is administered intravenously once every four weeks at a dose of about 7-10mg/kg of emedasat. In other embodiments, after pre-operative administration with an antihistamine, a corticosteroid, or both, the emedasat is administered intravenously at a dose of about 7.5mg/kg, alternatively about 7.0mg/kg to about 7.7mg/kg of emedasat once every four weeks.

In certain embodiments, the emedast is administered at a dose of about 7.5mg/kg, alternatively about 7.0mg/kg to about 7.7mg/kg, once every four weeks for at least three cycles, and then the dose is increased. In certain embodiments, if ANC and platelet nadir do not drop to about 1.5x10, respectively⁹L and about 75x10⁹between/L, and in the absence of grade 3 nonhematological toxicity, the dose of emedastine may be increased to about 9.4mg/kg, alternatively from about 8.8mg/kg to about 9.6 mg/kg.

It is to be understood that treatment of cancer sometimes involves multiple "rounds" or "cycles" of drug administration, wherein each cycle includes administering the drug one or more times according to a specified schedule (e.g., once every three weeks, for three consecutive days; once a week; etc.). For example, the anti-cancer drug may be administered for 1 to 8 cycles, or longer. When more than one drug (e.g., two drugs) is administered to a subject, each drug may be administered according to its own schedule (e.g., weekly, once every three weeks; etc.). It will be apparent that the administration of drugs, even those administered at different periods, may be coordinated so that both drugs are administered at least some time on the same day, or alternatively, so that the drugs are administered at least some time on consecutive days.

As understood in the art, if toxicity is observed, or for the convenience of the patient, treatment with a cancer treatment drug may be temporarily suspended and then resumed without departing from the scope of the invention.

In certain embodiments, the present invention relates to a telomerase inhibitor for use in a method of treating myelodysplastic syndrome (MDS), the method comprising administering to a subject in need thereof an effective amount of a telomerase inhibitor; wherein the subject has not been treated with an agent selected from the group consisting of hypomethylating agents (HMAs) and lenalidomide. In other embodiments, the invention relates to a telomerase inhibitor for use in a method of treating myelodysplastic syndrome (MDS), comprising administering to a subject in need thereof an effective amount of a telomerase inhibitor; wherein the subject has not been treated with an agent selected from the group consisting of HMA, lenalidomide, and combinations thereof.

In certain embodiments, the present invention relates to a telomerase inhibitor for use in a method as defined in any of the other embodiments.

H. Exemplary embodiments

Exemplary embodiments of methods of treating MDS of the present invention are shown in table a below, comprising administering an effective amount of a telomerase inhibitor to a subject in need thereof, whereby the subject is not treated with an agent selected from the group consisting of hypomethylated agents (HMA) and lenalidomide.

An exemplary embodiment comprises treating any one of the MDS shown in table a in any one of the subjects shown in table a with any one of the telomerase inhibitors shown in table a, whereby the subjects have not been treated with any one of the therapies shown in table a. In certain embodiments, one of the administration regimens described in table a is used. In other embodiments, the methods can be used to treat any one of the MDS shown in table a in any one of the subjects shown in table a using emedast (emedastine sodium), whereby the subject has not been treated with any one of the therapies shown in table a. When using imatinib (sodium imatinib), any of the administration regimens shown in table a may be used.

The following examples are provided by way of illustration and not limitation.

Examples of the invention

Example 1：Imitastat in low/moderate 1 risk myelodysplasia with the International Prognostic Scoring System (IPSS) ^TMTransfusion-dependent nature of syndrome (which is relapsed/refractory to Erythropoiesis Stimulating Agent (ESA) therapy (IMerge)) Therapeutic efficacy and safety in (TD) patients

Introduction to

IMerge^TM: a 2-part global study of exemestane sodium was performed in Red Blood Cell (RBC) Transfusion Dependent (TD) patients, ESA relapsed/refractory and lower risk MDS patients. Part 1 consists of an open one-armed design using the sodium exemestane monotherapy. This example provides safety and efficacy findings from 32 patients who included section 1. Subgroup analysis was also performed on patients who were not treated with lenalidomide and hypomethylating agent (HMA) and who did not have del (5 q). The results indicate improved efficacy in these patients.

Method

Qualification: the eligibility requirements for this study are as follows:

an adult diagnosed with MDS; international Prognostic Scoring System (IPSS) Low or Int-1

Transfusion Dependent (TD), defined as ≧ 4 units of Red Blood Cell (RBC) transfusion demand within 8 weeks prior to study entry.

40,000U per week of epoetin alfa or 150mcg of bepotastine alfa (or equivalent) or serum erythropoietin (sEPO) > 500mU/mL for at least 8 weeks, the ESA relapses or is refractory

Allow any previous therapy (containing lenalidomide or HMA). Patients with del (5q) karyotype were admitted regardless of prior treatment.

Eastern cooperative tumor group (ECOG) scores 0-2.

Absolute Neutrophil Count (ANC) ≥ 1.5x10⁹The sum of platelet is more than or equal to 75x10⁹L, independent of growth factors or transfusion support.

Liver function testing: AST, ALT and ALP ≦ 2.5 times upper normal limit (x ULN), total bilirubin ≦ 3x ULN, and direct bilirubin ≦ 2x ULN (unless due to Gilbert's syndrome).

Treatment: after pre-operative administration with antihistamines and corticosteroids, exemestane sodium was administered as an infusion for 2 hours every 4 weeks at a starting dose of 7.5 mg/kg. If ANC and platelet nadir were not reduced to 1.5X10, respectively⁹L and 75x10⁹(ii)/L or less, and no grade 3 non-hematologic toxicity, then allowing for an escalation of the dose to 9.4mg/kg after at least 3 cycles at the initial dose for insufficient response. Allowing supportive care including blood transfusion and bone marrow growth factors as clinically indicated.

Endpoint and analysis:

primary end point: RBC Transfusion Independent (TI) rates lasting > 8 weeks.

Key secondary endpoint:

safety of o

The TI rate is more than or equal to 24 weeks;

time and duration to reach TI;

omicron Hematological Improvement (HI) rate; and

complete Response (CR) and Partial Response (PR) rates per International Working Group (IWG).

Results

Patient's health

Baseline median RBC transfusion burden, 6 units/8 weeks (range: 4-14)

Baseline characteristics are shown in table 1 below. The following abbreviations are used in table 1: an east cooperative oncology group performance status score of 0-1 ("ECOG PS 0-1"); refractory anemia with cyclic sideroblasts ("RARS"); or refractory cytopenia with multiple sets of dysplasia and cyclic sideroblasts ("RCMD-RS").

Key hematological criteria: ANC 1,500 and PLT 75,000. This is a group of heavily transfused patients based on the baseline RBC transfusion burden.

Results (first data snapshot)

Exposing

Median follow-up of this analysis: 66.1 weeks

Median of treatment cycles: 6.5 (Range: 1-20 cycles)

16 patients (50%) with dose reduction and 19 patients (59%) with periodic delay due to adverse events

Elmestat sodium dose escalation to 9.4mg/kg in 7 patients

Therapeutic effect

The key efficacy results are shown in table 2 below.

The primary endpoint of RBC TI was reached in 12/32 (38%) patients for > 8 weeks.

5/32 (16%) reached a 24 week TI (see fig. 1A, 1B and fig. 2). These patients also achieved sustained elevation of hemoglobin by at least 1.5g/dL (HI-E Hb) within 8 weeks (HI-E Hb — HI-E, where hemoglobin is continuously elevated by at least 1.5g/dL within 8 weeks). The duration of TI in patients (65.1 weeks) exceeds one year.

20/32 (63%) patients had erythroid Hematological Improvement (HI) (see FIGS. 1A and 1B).

In the subset of patients who had not used lenalidomide and HMA and were deficient in del (5q), the TI rates at 8 and 24 weeks were 54% and 31%, respectively (higher than the general population), and the erythroid HI rate was 69% (similar to that reported in the general population). Complete Response (CR) and bone marrow CR (mCR) were reported for each of 2 patients, and in the absence of Partial Response (PR), the CR + PR + mCR rate was 13%.

One CR and two mCR were in a subset of patients who had not used lenalidomide and HMA and lacked del (5 q). Based on the presence of cyclic sideroblasts (RS), there was no difference in TI at 8 weeks: 38% for RS + (6/16) and 38% for RS- (6/16). The response appears to be independent of epo levels; of the 30 reported patients with baseline epo levels: 41 percent (7/17) of sEPO level less than or equal to 500mU/L reaches TI more than or equal to 8 weeks; and 38% (5/13) of sEPO levels > 500mU/L reached a TI > 8 weeks.

Safety feature

Cytopenia, especially neutropenia and thrombocytopenia, are the most frequently reported adverse events in general and in the unused lenalidomide and HMA and lacking the subset of del (5q) (see table 3 below). This subset of patients had a lower incidence of neutropenia rating ≧ 3, but a similar incidence of thrombocytopenia rating ≧ 3, relative to the overall population (see Table 4 below). In most cases, grade ≧ 3 cytopenia was reversible within 4 weeks with no clinical sequelae, and patients were able to continue eimestat sodium treatment after dose adjustment.

1 patient (of 22 patients with neutropenia) presented with a neutropenic fever, 2 patients (of 18 patients with thrombocytopenia) had grade 3 thrombocytopenia with a grade 1 bleeding event, all of which were considered to be associated with exemestane sodium; these events recovered without sequelae. 28 patients (88%) had elevated Liver Function Tests (LFTs) by at least one step. These events are typically either level 1 or level 2 and may be reversed. 4 patients (including 3 of a subset of patients who have not used lenalidomide and HMA and lack del [5q ]) have grade 3 exacerbations of aspartate Aminotransferase (AST) and/or alanine Aminotransferase (ALT), and 1 of these patients has grade 3 exacerbations of bilirubin; all of these are reversible.

Table 3 shows the most common treatment-induced adverse events. Table 4 shows the maximum level of change from baseline for cytopenia.

The results in table 4 are based on the first data snapshot.

Results (second data Snapshot)

Exposing

Median follow-up of this analysis: for 95 weeks

Median of treatment cycles: 6.5 (Range: 1-28 cycles)

16 patients (50%) with dose reduction and 19 patients (59%) with cycle delay

Elmestat sodium dose escalation to 9.4mg/kg in 7 patients

Therapeutic effect

Table 5 below shows the primary efficacy results of the second data snapshot.

The longest follow-up time for responding patients was 115 weeks or 26 months.

Of the 7 subjects in ascending doses, 1 subject reached 8 weeks TI, and 3 subjects reached HI-E. The median number of treatment cycles for the subgroup was 8 cycles. Median duration for total and subgroup therapy was 24 weeks and 29 weeks, respectively.

Fig. 3A shows the longest transfusion free interval time at the second data snapshot. TI was still receiving treatment at week 24 in three of the five patients. The data shown in fig. 3A is summarized in table 6 below:

fig. 3B shows the absolute change in blood volume delivered over the optimal 8-week interval. 1 patient with a transfusion burden of 10 dropped to 0. Patients who did not reach TI (HI-E (TR)) had some quite meaningful reduction in transfusion burden. The data shown in fig. 3B is summarized in table 7 below:

figure 4 shows the efficacy results of the EPO and RS subgroups at the second data snapshot. Similar therapeutic effects were observed in these subgroups. Figure 5 shows hematology and emetas sodium administration of the patient over time at the second data snapshot. Figure 6 shows hemoglobin and emedastine sodium dosing in patients with persistent TI. The first three patients in figure 6 were still receiving treatment. The first two subjects in figure 6 had the longest follow-up time.

Safety feature

Safety results for patients who did not use lenalidomide/HMA/non-del (5q) were similar to the population in the overall study.

Table 8 shows the most common treatment emergent adverse events at the second data snapshot. Table 9 shows the incidence and reversibility of grade 3/4 cytopenia. Table 10 shows the maximum post-baseline adverse event generic term criteria (CTCAE) rating, worsening from baseline setting for cytopenia by population and safety analysis at second data snapshot.

During the study 11 patients received G-CSF for the treatment of adverse events or a persistent medical history (n-10) or as a preventive measure (n-1).

Observations (based on two data snapshots)

Safety and efficacy data for 32 patients in part 1 of the study supported continued to study the sodium imatinib using the current 7.5mg/kg dose regimen (once every 4 weeks).

At the time of the first data snapshot, 38% of IPSS low/medium 1RBC transfusion-dependent MDS patients who were relapsed/refractory to ESA exhibited 8 weeks RBC TI, and 63% exhibited erythroid HI. TI was observed in 16% of patients for 24 weeks, while Hb continued to rise.

At the first data snapshot, 54% RBC TI was observed in 13 patients without del (5q) and without prior exposure to lenalidomide or HMA (compared to 38% in the overall population), and the response was more durable (31% TI rate at 24 weeks).

Overall, 8-week TI was observed in 34% of all patients, with a 24-week TI rate of 16%. The median time to TI was 8.0 weeks. The median duration of TI was 23.1 weeks.

For patients who did not use lenalidomide/HMA and were not del (5q), TI rates were 54% and 31% at 8 weeks and 24 weeks, respectively. For these patients, the median duration of TI was 42.9 weeks.

Overall, TR (HI-E) was observed in 59% of all patients. The mean relative reduction in RBC transfusion burden from baseline was 60%.

These results support further studies of exemestane sodium (7.5mg/kg/4 weeks) in IPSS low/moderate 1, TD, ESA-relapsed/refractory MDS. In RBC TD patients with LR-MDS (median: 6U/8 week), treatment with exemestane sodium resulted in improvement of the erythroid line in most patients.

The study was repeated for a target population of 13 subjects with non-del (5q) MDS who had not been previously exposed to HMA or lenalidomide. In this target population, 53.8% reached the primary endpoint of 8-week RBC TI compared to 21.1% of other subjects not in the target population. The response was more persistent in the target population than in other subjects (median duration, 42.9 weeks versus 13.9 weeks), and more subjects in the target population reached 24 weeks RBC TI (30.8% versus 5.3%). The target population exhibits a comparable or better safety profile of cytopenia and other adverse events, and cytopenia appears to resolve more rapidly in the target population.

Example 2: results of the third data snapshot

A third data snapshot was taken with a clinical cutoff of 2018, 10 and 26 days. In addition, 25 patients who had not used lenalidomide and HMA (without del (5q)) were included, and the group was compiled for the first 13 patients who had not used lenalidomide and HMA (without del (5 q)). N-38 patients in total.

Median follow-up was 29.1 months for the first 13 patients. Median follow-up was 8.7 months for the other 25 patients.

Median number of treatment cycles: 8.0 (range: 1-34) cycles. The average dose strength was 6.9 mg/kg/cycle.

Table 11: IMerge: key therapeutic effect results

Parameter(s)	N＝38
		TI Rate of 8 weeks, n (%)	14(37)
24-week TI Rate, n (%)	10(26)
		Median time (range) of onset of TI, week	8.1(0.1-33.1)
Median duration (range) of TI week	NE(17.0-NE)
		Blood transfusion reduction ratio (HI-E), n (%)	27(71)
Mean relative reduction of RBC transfusion burden from baseline%	-68
		CR + bone marrow CR + PR (per IWG), n (%)	8(21)

CR, complete remission; HI-E, hematology improvement-erythroid; IWG, international working group; NE, not estimable; PR, partial remission; RBC, red blood cells; TI, transfusion independent.

Example 3: result of the fourth data snapshot

A fourth data snapshot was taken with a clinical expiration date of 2019, 1 month, 23 days, reported in the data from IMerge^TMOpen one-arm part 1 of 38 LR non-del (5q) MDS patients studiedMedian follow-up was 12.1 months of updated efficacy data (relapsed/refractory to ESA and no use of lenalidomide/HMA).

Method

IMerge^TMPart 1 of the study included patients with low or moderate 1IPSS risk MDS (LR-MDS) who were heavily transfused (> 4U/8 weeks), were relapsed/refractory to ESA, or > 500mU/mL of epo. Every 4 weeks IMETASTAR 7.5mg/kg was injected intravenously. The primary endpoint was Transfusion Independent (TI) rate for 8 weeks; key secondary endpoints included 24-week TI rate, safety, duration of TI, and Hematology Improvement (HI) rate. Among the patients initially enrolled, a higher 8-week TI rate was observed in non-del 5q, lenalidomide/HMA naive patients. Therefore, the study was revised to include only these patients later. Of the total 57 patients enrolled in section 1, 38 were non-del (5q), unused lenalidomide/HMA patients (13 in the initial cohort, 25 in the extended cohort). Long-term efficacy, safety and biomarker data from these 38 patients were reported.

Results

The median previous RBC transfusion burden was 8 units/8 weeks (ranging from 4-14), with 37% of patients having IPSS Int-1; 71% have WHO 2008RARS (refractory anemia with cricoid granulocytes) or RCMD-RS (refractory cytopenia with multisystemic dysplasia and cricoid granulocytes) subtypes and 32% with appreciable sEPO (serum erythropoietin) levels have baseline levels > 500 mU/mL.

1, 23 days in 2019, and the median follow-up is 12.1 months; the first 13 patients were 30.4 months, and the other 25 patients were 11.6 months, respectively. The 8-week TI rate was 45% (17/38), and the median TI duration was 8.5 months (range 1.8-32.4). Of the 17 responding patients, 10 (59%) had no blood transfusions for more than 6 months. There was no difference in TI rates at 8 weeks based on the presence of cricotrione granulocytes or baseline epo levels. The 24-week TI rate was 26% (10/38), with a median duration of 10.5 months (range 8.3-32.4). 68% (26/38) achieved erythrohematological improvement (HI), defined as a > 50% reduction in transfusion burden, for at least 8 weeks. The most commonly reported adverse events are grade 3 cytopenia, which is controllable and reversible.

Summary of the invention

In patients with high RBC transfusion burden of non-del (5q) LR-MDS who are relapsed/refractory to ESA and have no used lenalidomide/HMA, the single agent eimestat produces an 8-week TI rate of 45% with a median duration of 8.5 months (range 1.8-32.4). The 24-week TI rate was 26%, with a median duration of 10.5 months (range 8.3-32.4 months). All patients with IPSS-R median and poor cytogenetic risk responded. Biomarker analysis of telomerase activity and mutant allele burden indicated an effect on malignant mutant clones, as described below.

Example 4: biomarker data

In IMerge^TMDuring the course of the study, various biomarkers were monitored and evaluated, including telomerase hTERT RNA levels, Telomerase Activity (TA), cytogenetic data, and mutation data. The expression level of hTERT RNA was measured in whole blood samples taken from patients before and after treatment. The results are summarized below.

Greenberg et al (Revised International Prognostic Scoring System for Myelodysplastic Syndromes), blood, 9.2012, 20 days, 120(12) 2454-2465 (the disclosure of which is incorporated herein by reference in its entirety) describe a Revised International Prognostic Scoring System (IPSS-R) for assessing the prognosis of primary untreated adult patients with MDS. Table 2 of Greenberg et al lists the MDS cytogenetic scoring system reproduced below as Table 12 and used for IMerge^TMThe patients studied were classified.

Table 12: greenberg et al MDS cytogenetic scoring system.

OS represents overall lifetime; NR, not reached.

Data from patients in the international working group (IWG-PM) database for MDS prognosis, multivariate analysis (n 7012).

Data from Schanz et al ("New comprehensive cytogenetic scoring system for primary myelodysplastic syndromes and oligoblast AML from International database pooling after MDS)", J.Clin.Oncology 2012; 30(8): 820: 829) (n.2754).

PD effect: telomerase hTERT Reduction of RNA levels

Table 13: hTERT RNA expression analysis (hTERT) at third data snapshot

At the fourth data snapshot, a decrease in post-treatment telomerase hTERT RNA levels was observed in patients with 25/34 (73.5%) of available samples. See also fig. 7.

Association between hTERT reduction and response

A higher percentage of subjects achieved ≧ 50% reduction in hTERT RNA expression levels in 8-week Transfusion Independent (TI) responders as compared to non-responders.

Table 14: hTERT response by TI was at least 50% lower from baseline at the third data snapshot.

PD effect: telomerase Activity (TA)

Some patients had a decrease in TA after treatment.

Table 15: subjects with decreased Telomerase Activity (TA) from baseline at the third data snapshot.

	N with data	TA is not less than 50 percent	TA is reduced by more than or equal to 30 percent
				Base line	16
Cycle 1 day 1-24 hours	5	1(20％)	3(60％)
				Cycle 1 day 8	6	2(33％)	3(50％)

Variation of frequency of mutant variants

At the third data snapshot, 6 subjects had the SF3B1 mutation at baseline, and a decrease in variant frequency was observed in 2 subjects with the longest TI duration. One subject had a reduction in the DNMT3A mutation and a substantial reduction in bone marrow cyclic iron granulocytes (75% to 3%).

At the fourth data snapshot, of the 7 patients undergoing pre-and post-treatment mutation analyses, 6 had the SF3B1 mutation at baseline, and a decrease in mutant variant allele frequency was observed in the 2 patients with the longest TI duration in the study.

Risk of cytogenetics

Patients were classified according to the revised International prognostic Scoring System (IPSS-R), as shown in Table 12.

At the fourth data snapshot, 6 of 38 patients had a moderate/poor cytogenetic risk of IPSS-R, and 5 of 6 patients reached 8-week TI; 2/6 achieve a partial cytogenetic response.

Summary of the invention

A decrease in telomerase activity/hTERT RNA levels after treatment was observed in a subset of subjects, indicating the PD effect of emedastine. Subjects achieving > 50% reduction in hTERT compared to non-responders are enriched in 8-week TI responders

The majority of subjects were in the good or intermediate cytogenetic risk category, and an 8-week Transfusion Independent (TI) response has been observed. At the third data snapshot, two subjects with poor cytogenetic risk did not have TI responses. By the fourth data snapshot, however, 6 of 38 patients with moderate/poor cytogenetic risk of IPSS-R, 5 of 6 patients reached 8 week TI; 2/6 achieve a partial cytogenetic response.

Of 7 subjects with pre-and post-treatment mutant samples, 6 had the SF3B1 mutation at baseline, and a change in mutant variant frequency was observed in the patient with the longest TI duration.

Example 5：A number of treatments with emedast that are relapsing/refractory to erythropoiesis-stimulating agents (ESA) Transfused patients with non-del (5q) lower risk myelodysplastic syndrome

This example provides incorporation of IMerge from 38 cases^TMThe study guidance is described in more detail above for patient safety and efficacy findings. The results provided by this example indicate that in this patient group, treatment with imatinib resulted in a meaningful and persistent transfusion independence.

Method

Qualification: the eligibility requirements for this study are as follows:

an adult diagnosed with MDS; international Prognostic Scoring System (IPSS) Low or Int-1

Transfusion Dependent (TD), defined as ≧ 4 units of Red Blood Cell (RBC) transfusion demand within 8 weeks prior to study entry.

ESA relapsing or ESA refractory or serum erythropoietin (sEPO) > 500mU/mL

Patients were non-del (5q) and unused lenalidomide or HMA.

Patients ranging in age from 46 to 83 years, with a median of 71.5 years

Eastern cooperative tumor group (ECOG) score PS 0-1.

Treatment: after pre-operative administration with antihistamines and corticosteroids, exemestane sodium was administered as an infusion for 2 hours every 4 weeks at a starting dose of 7.5 mg/kg. If ANC and platelet nadir were not reduced to 1.5X10, respectively⁹L and 75x10⁹(ii)/L or less, and no grade 3 non-hematologic toxicity, then allowing for an escalation of the dose to 9.4mg/kg after at least 3 cycles at the initial dose for insufficient response. Allowing supportive care including blood transfusion and bone marrow growth factors as clinically indicated.

Results

Patient's health

Baseline median RBC transfusion burden, 8 units/8 weeks (range: 4-14)

The baseline characteristics are shown in table 16 below. The following abbreviations are used in table 16: an east cooperative oncology group performance status score of 0-1 ("ECOG PS 0-1"); refractory anemia with cyclic sideroblasts ("RARS"); or refractory cytopenia with multiple series of dysplasias and cyclic sideroblasts ("RCMD-RS"); RAEB-1: refractory anemia is associated with an excess of primary cells.

Results

Exposing

Median follow-up of this analysis: 15.7 months

Median of treatment cycles: 9 (Range: 1-39 cycles)

Therapeutic effect

The key efficacy results are shown in table 17 below.

Primary endpoints of RBC TI for > 8 weeks were achieved in different subgroups as shown in Table 18:

of 34 patients with baseline cytogenetic data:

6/34 (18%) with moderate or poor cytogenetic risk (see Table 19)

5/6 (83%) reached 8 weeks Transfusion Independence (TI), and all patients were of the cyclic sideroblasts WHO subtype

3/3 with trisomy 8 achieved 8-week Transfusion Independence (TI), and 2/3 achieved 24-week Transfusion Independence (TI)

2/3 with available post-treatment cytogenetic data to achieve a partial cytogenetic response

Effect of Eimestat on malignant cloning

2/6 patients with the baseline SF3B1 mutation had a reduction in variant allele frequency and maintained transfusion-independent (TI) for more than one year (Table 20)

Table 20: effect of Eimestat on malignant cloning
	TI: transfusion independence

Of 16 patients who reached 8 weeks Transfusion Independent (TI):

transfusion-independent (TI) median duration of 86 weeks (range: 8-141 weeks)

11/16 (69%) to achieve 24-week Transfusion Independent (TI) rates

12/16 (75%) had an increase in Hgb from the pre-treatment level of ≥ 3g/dL

Mean relative reduction in RBC transfusion burden from baseline of 68%

Safety feature

Adverse effects included thrombocytopenia, neutropenia and anemia (Table 21)

For neutrophils, 91% resolved within 4 weeks, while 9% did not resolve within 4 weeks. For platelets, 92% resolved within 4 weeks, while 8% did not resolve within 4 weeks. 2/38 patients (5%) had febrile neutropenia. 4/38 patients (10%) had bleeding episodes, 2/38 (5%) was on a 3/4 scale.

Targeting activity was demonstrated by a decrease in telomerase activity and hTERT expression (table 23). The results showed that patients with transfusion-independent (TI) had higher reductions in hTERT expression (Table 24)

50% reduction is the PD effect shown as correlation with in vivo anti-tumor activity from preclinical xenograft models

50% reduction is the PD effect shown as correlation with in vivo anti-tumor activity from preclinical xenograft models

Overall, 8-week TI was observed in 42% of all patients, with a 24-week TI rate of 29%. Transfusion-independent (TI) median duration was 20 months. Overall, TR (HI-E) was observed in 68% of all patients.

Transfusion independence was observed in different clinical subgroups, including patients with moderate/poor cytogenetic risk. Biomarker data indicate potential impact on malignant clones and disease modification.

Although certain specific embodiments have been described in some detail by way of illustration and example for purposes of clarity of understanding, it will be readily apparent from the teachings of the present invention that certain changes and modifications may be made therein without departing from the spirit or scope of the appended claims.

Accordingly, the foregoing merely illustrates the principles of the invention. Various arrangements may be devised which, although not explicitly described or shown herein, embody the principles of the invention and are included within its spirit and scope. Furthermore, all examples and conditional language recited herein are principally intended expressly to aid the reader in understanding the principles of the invention and the concepts contributed by the inventor to furthering the art, and are to be construed as being without limitation to such specifically recited examples and conditions. Moreover, all statements herein reciting principles, aspects, and embodiments of the invention, as well as specific examples thereof, are intended to encompass both structural and functional equivalents thereof. Additionally, it is intended that such equivalents include both currently known equivalents as well as equivalents developed in the future, i.e., any elements developed that perform the same function, regardless of structure. Thus, the scope of the present invention is not intended to be limited to the exemplary embodiments shown and described herein. Rather, the scope and spirit of the invention is embodied by the appended claims.